M. Alexander Otto

LOS ANGELES – It’s reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug’s associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

"I don’t have any problem with that," he said, when an audience member suggested it and also noted the drug’s teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, "the folks [who] gain all that weight on olanzapine don’t get PCOS," Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they’re "not worth doing," he said.

The reason is that 10%-15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren’t always present in PCOS.

When women are started on the drug, ask them "every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse," Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal.

Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, Dr. Carlson said.

He said he is a consultant to Eli Lilly & Co. He also disclosed receiving research funding from GlaxoSmithKline.

LOS ANGELES – It’s reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug’s associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

"I don’t have any problem with that," he said, when an audience member suggested it and also noted the drug’s teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, "the folks [who] gain all that weight on olanzapine don’t get PCOS," Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they’re "not worth doing," he said.

The reason is that 10%-15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren’t always present in PCOS.

When women are started on the drug, ask them "every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse," Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal.

Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, Dr. Carlson said.

He said he is a consultant to Eli Lilly & Co. He also disclosed receiving research funding from GlaxoSmithKline.

LOS ANGELES – It’s reasonable to consider the anticonvulsant valproate as a last option for women with bipolar disorder, given the drug’s associations with the risk of developing isolated features of polycystic ovary syndrome, according to Dr. Harold Carlson.

"I don’t have any problem with that," he said, when an audience member suggested it and also noted the drug’s teratogenicity.

Women under age 25, and particularly adolescents in their midteens, are most at risk for valproate-induced PCOS, usually within the first year of treatment, said Dr. Carlson, professor of endocrinology at Stony Brook (N.Y.) University.

In one study, 9 of 86 women with bipolar disorder (10.5%) treated with valproate developed PCOS; 2 of 144 women with bipolar disorder (1.4%) developed PCOS when treated with other mood stabilizers (Biol. Psychiatry 2006;59:1078-86).

Valproate seems to pose a particular risk for the condition driven by something more than the weight gain caused by the drug.

After all, "the folks [who] gain all that weight on olanzapine don’t get PCOS," Dr. Carlson noted.

Valproate appears to act directly on the ovaries, altering their hormone production. Cultured ovarian cells produce more testosterone in its presence. The excess testosterone shuts off menstruation, and causes acne and hirsutism. Obesity, insulin resistance, and dyslipidemia are problems in PCOS, as well.

When valproate cannot be switched out for a mood stabilizer, prescribing birth control pills at the start of therapy might be a smart move, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry. That appeared to help prevent PCOS in valproate-treated women in one study (Seizure 2003;12:323-9).

Baseline pelvic ultrasounds might seem like a good idea, too, but they’re "not worth doing," he said.

The reason is that 10%-15% of healthy women have cysts on their ovaries without having PCOS, and ovarian cysts aren’t always present in PCOS.

When women are started on the drug, ask them "every time you see them about their menstrual function. Look at them and see if they are getting acne and hirsutism. Ask them about it. Provide some counseling on diet and exercise to avoid the excessive weight gain, which only makes it worse," Dr. Carlson said.

Should PCOS develop, Metformin is the first-line symptom treatment. Clomiphene can induce ovulation if pregnancy is the goal.

Endocrinology, urology, or gynecology referrals also are in order to help with symptoms, Dr. Carlson said.

He said he is a consultant to Eli Lilly & Co. He also disclosed receiving research funding from GlaxoSmithKline.

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.

LOS ANGELES – When conventional approaches fail to help autistic children, parents who suggest alternative treatments should not be ignored, according to Dr. Robert L. Hendren.

Instead, it’s better to talk to them about their ideas and keep an open mind, said Dr. Hendren, director of child and adolescent psychiatry at the University of California, San Francisco. "I try to weigh the evidence [with families], but if they’re doing something I think is dangerous, or they’re avoiding other kinds of treatments, I tend to tell them," he said.

When there’s no harm to an alternative treatment, after a few months, Dr. Hendren said he will help parents assess whether it is working and ask them to reconsider his treatment ideas.

The reasoned approach means parents feel comfortable telling him the alternatives they’re trying and letting alternative practitioners know that Dr. Hendren is involved in the case, he said. Also, with evidence emerging that mitochondrial dysfunction, chronic inflammation, maternal toxin exposure, oxidative stress, and other problems might play a role in autism, some treatments now considered alternative eventually might prove useful, he said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Hendren analyzed the evidence – or lack thereof – for many of the currently hot complementary and alternative approaches.

Casein and gluten-free diets are among them. There’s no harm, so long as families work with nutritionists to ensure that children get enough calcium and protein, he said. There’s no harm in trying glutathione, vitamin D, and omega-3 fatty acids, either; Dr. Hendren, in fact, prescribes the latter two for his own patients. Evidence is lacking, however, for amino acids, thyroid supplements, and antifungals. "I don’t think the jury is in on methyl B12 [injections] yet," he said.

Chelation is hot for autism, too, but "I don’t think there’s any reason to try it," he said. "I don’t tell parents that they ought to do it, but I say at least find somebody who knows what they’re doing," he said.

Therapy and Medications

What’s known to help autistic children, among other things, are speech and occupational therapy, cognitive-behavioral treatments, social skills training, and reducing stress by, for instance, removing children from upsetting situations.

Medications can help, too.

For children with comorbid attention-deficit/hyperactivity disorder, stimulants "can make a big difference in their inattention," Dr. Hendren said.

He said he favors immediate-release formulations, titrated up slowly from low doses, and warns parents that stimulants might temporarily unhinge their child.

If that happens, atomoxetine is an option, though stimulants seem to work better for inattention, Dr. Hendren said.

Short-acting tranquilizers like lorazepam help anxiety, especially in tense situations like a visit to the doctor’s office.

As with stimulants, Dr. Hendren said he starts low – 0.5 mg, for example – and slowly titrates up to effect, perhaps going as high as 1 or 2 mg.

"A number of kids do quite well on alpha-adrenergic agonists" as well, he said.

The drugs "seem to help dampen them down, and can be especially useful in some of the younger kids [who] are just very hyperactive and having a lot of difficulty with their impulsivity," he said.

Clonidine is a bit more sedating than guanfacine (Tenex), which can be a benefit.

And some kids do well on Intuniv, the long-acting guanfacine formulation, but "parents don’t like paying that extra price" for the newer medication, Dr. Hendren said.

Topiramate also helps calm anxious children, but Dr. Hendren said he avoids exceeding 75 mg, because the drug can make children squirrelly.

Melatonin helps with sleep problems, "but at times we need to titrate up to as high as 6 or even 8 or 9 mg," he said.

Selective serotonin reuptake inhibitors (SSRIs) might help curb impulsive and compulsive behavior, though a recent study raises doubts about their use in autism (Arch. Gen. Psychiatry 2009;66:583-90). SSRI activation remains a concern, as well.

Among Dr. Hendren’s colleagues, the preference is for escitalopram or sertraline, because these drugs seem less activating. Again, titration is slow from a low dose. He said he prefers "escitalopram because I find I can usually get within range with 20 mg; occasionally I’ll go to 30 mg." Sertraline requires higher dosages. Also, "I like the side effect profile better," he said.

Atypicals and Other Options

Risperidone and aripiprazole, the only drugs approved for autism symptoms, both help irritability, behavior problems, and children who become easily unglued, Dr. Hendren said.

But atypical antipsychotics are associated with significant side effects, including weight gain, sedation, and salivation.

"I’ve had three kids in my practice [who] developed clear symptoms of tardive dyskinesia on risperidone that went away when the medication was taken away," he said. "Some parents are willing to take the risk, but it’s a risk I have them write about."

He’s also had younger girls or boys develop breast buds on risperidone and lactate. In those cases, he usually switches to aripiprazole, though sometimes, children don’t do as well.

Lowering the risperidone dose is another option. "I have some children [whom] I’ve kept just below lactating on risperidone," he said.

When all else fails, there’s some evidence to support propranolol and low-dose naltrexone cream for aggression; divalproex might help affect instability.

Amantadine, d-cycloserine, memantine, cholinesterase inhibitors, and nicotinic agonists all have studies suggesting a small effect size, he said.

Dr. Hendren disclosed that he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from that company plus Curemark LLC, Forest Laboratories Inc., and Autism Speaks.

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the Swedish Medical Center symposium on "Innovations in the Age of Reform."

They weren’t just talking about lower-intensity care, either.

Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing – and disseminating – the "Hospital at Home" care model.

It’s about "true acute care," he said, "taking someone from the emergency department [where a] physician has said ‘this person needs to be admitted’ "for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, "and other things that people end up in the hospital for," and treating that person at home.

The "best way this works is when the ‘Hospital at Home’ is thought of as a virtual unit of the acute hospital. Recently, we’ve been partnering with proto-ACOs [accountable care organizations] that are very interested in this model," said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said.

First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won’t add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren’t thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, "they’re dead; they’re gone," he said.

The trend toward home care has been embraced by one of the nation’s largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. "We are increasingly investing in home care because 40% of our discharges are going to home care" already. "That’s where we see an opportunity for our patients and our shareholders," he said.

He and others said they think technology will further the trend.

Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention.

If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision "a lightweight, simple package caregivers can purchase from Home Depot or Lowe’s" that would be capable of remote, hospital-level monitoring. The idea is to empower patients to "do as much as they can at home and avoid leaving their personal space to get care," she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It "gives you everything you get in the ICU now, with 14 different probes and needles," he said.

"Hospital at Home" is already "a pretty intense intervention" that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Patients can live alone, and nursing assistants ("a relatively cheap" addition) can help with daily activities if needed, he said.

About 90% of patients opt for home treatment if it is offered; the elderly in particular do better at home, with lower rates of delirium and functional decline and higher rates of care satisfaction, Dr. Leff said.

"I think we are [still] going to need hospitals. Intensive care is critical. Many people would like to deliver their babies in the hospital. A hospital [will be] where you will go for brief, ultraspecialized, high-tech care," he said.

"But I do think a lot of the other stuff is going to move out," Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the Swedish Medical Center symposium on "Innovations in the Age of Reform."

They weren’t just talking about lower-intensity care, either.

Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing – and disseminating – the "Hospital at Home" care model.

It’s about "true acute care," he said, "taking someone from the emergency department [where a] physician has said ‘this person needs to be admitted’ "for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, "and other things that people end up in the hospital for," and treating that person at home.

The "best way this works is when the ‘Hospital at Home’ is thought of as a virtual unit of the acute hospital. Recently, we’ve been partnering with proto-ACOs [accountable care organizations] that are very interested in this model," said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said.

First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won’t add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren’t thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, "they’re dead; they’re gone," he said.

The trend toward home care has been embraced by one of the nation’s largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. "We are increasingly investing in home care because 40% of our discharges are going to home care" already. "That’s where we see an opportunity for our patients and our shareholders," he said.

He and others said they think technology will further the trend.

Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention.

If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision "a lightweight, simple package caregivers can purchase from Home Depot or Lowe’s" that would be capable of remote, hospital-level monitoring. The idea is to empower patients to "do as much as they can at home and avoid leaving their personal space to get care," she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It "gives you everything you get in the ICU now, with 14 different probes and needles," he said.

"Hospital at Home" is already "a pretty intense intervention" that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Patients can live alone, and nursing assistants ("a relatively cheap" addition) can help with daily activities if needed, he said.

About 90% of patients opt for home treatment if it is offered; the elderly in particular do better at home, with lower rates of delirium and functional decline and higher rates of care satisfaction, Dr. Leff said.

"I think we are [still] going to need hospitals. Intensive care is critical. Many people would like to deliver their babies in the hospital. A hospital [will be] where you will go for brief, ultraspecialized, high-tech care," he said.

"But I do think a lot of the other stuff is going to move out," Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

SEATTLE – Home health care will increasingly replace hospital care, panelists said during a discussion of the phenomenon at the Swedish Medical Center symposium on "Innovations in the Age of Reform."

They weren’t just talking about lower-intensity care, either.

Consider the work of panelist Dr. Bruce Leff and his colleagues at Johns Hopkins University in Baltimore, who are among those developing – and disseminating – the "Hospital at Home" care model.

It’s about "true acute care," he said, "taking someone from the emergency department [where a] physician has said ‘this person needs to be admitted’ "for pneumonia, heart failure, chronic obstructive pulmonary disease, cellulitis, deep vein thrombosis, "and other things that people end up in the hospital for," and treating that person at home.

The "best way this works is when the ‘Hospital at Home’ is thought of as a virtual unit of the acute hospital. Recently, we’ve been partnering with proto-ACOs [accountable care organizations] that are very interested in this model," said Dr. Leff, a Hopkins geriatrician and professor of medicine.

Several things are driving the trend, he and other panelists said.

First, payers are looking to cut costs by cutting hospital admissions. Also, hospital executives want to empty their beds of patients on whom they lose money; patients generally prefer treatment at home; elderly patients usually do better there; and technology increasingly enables hospital-level home care, panelists said.

Hospitals are already being built with fewer beds than they might have had a decade ago. A $1 billion high-tech tower being built at Johns Hopkins won’t add any more beds to the campus, Dr. Leff noted.

Given the trend, if hospitals aren’t thinking about how to focus on high-margin patients and effectively treat others in lower-cost settings, "they’re dead; they’re gone," he said.

The trend toward home care has been embraced by one of the nation’s largest health care companies, Louisville, Ky.–based Kindred Healthcare Inc., according to CEO Paul Diaz, also a panelist. "We are increasingly investing in home care because 40% of our discharges are going to home care" already. "That’s where we see an opportunity for our patients and our shareholders," he said.

He and others said they think technology will further the trend.

Diane Cook, Ph.D., a professor of electrical engineering who was also a panelist, gave an example of what could be coming soon. She and her colleagues at Washington State University, Pullman, have rigged an apartment on campus with sensors (motion detectors, for instance, and stove-burner monitors) to see if the feedback accurately indicates how well patients – especially the elderly – perform day-to-day tasks, and if they need intervention.

If the technology proves itself, it could reduce unnecessary home-health visits, saving providers time and money.

Dr. Cook and her colleagues ultimately envision "a lightweight, simple package caregivers can purchase from Home Depot or Lowe’s" that would be capable of remote, hospital-level monitoring. The idea is to empower patients to "do as much as they can at home and avoid leaving their personal space to get care," she said.

Meanwhile, Dr. Leff and his colleagues are planning to pilot an adhesive strip–like sensor that could be used in the home. It "gives you everything you get in the ICU now, with 14 different probes and needles," he said.

"Hospital at Home" is already "a pretty intense intervention" that can include IV medications; oxygen and respiratory therapy; and x-rays, ultrasounds, and diagnostic labs, among other things, Dr. Leff said.

Patients can live alone, and nursing assistants ("a relatively cheap" addition) can help with daily activities if needed, he said.

About 90% of patients opt for home treatment if it is offered; the elderly in particular do better at home, with lower rates of delirium and functional decline and higher rates of care satisfaction, Dr. Leff said.

"I think we are [still] going to need hospitals. Intensive care is critical. Many people would like to deliver their babies in the hospital. A hospital [will be] where you will go for brief, ultraspecialized, high-tech care," he said.

"But I do think a lot of the other stuff is going to move out," Dr. Leff said.

Dr. Leff said he has no personal conflicts of interest. His research is supported in part by fees paid to Johns Hopkins for his consulting services. Dr. Cook said she did not currently have any disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – There is very little evidence – and in some cases none at all – to support common pharmacologic treatments for anorexia and bulimia nervosa, according to Michael Strober, Ph.D.

Eating disorders "are the black hole of pharmacotherapy in psychiatry. There’s not much at this point in time we have to offer," Dr. Strober, director of the eating disorders program at the UCLA Neuropsychiatric Institute and Hospital, reported at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.

For anorexia nervosa, evidence is stronger for family-based therapy in which families are taught to help a child eat and maintain weight.

Cognitive-behavioral therapy (CBT) is more effective than drugs for bulimia nervosa and remains its treatment of choice, said Dr. Strober, who estimated he’s treated more than 8,000 eating disorder patients during a career dating back to 1975.

Although selective serotonin reuptake inhibitors (SSRIs) are widely used to treat anorexia, "there is absolutely not a speck of evidence that these drugs, in the acutely malnourished state, are effective," or that they help maintain weight gain, said Dr. Strober, who also serves as director of the adolescent mood disorders program at the institute.

There is slight evidence for the atypical antipsychotic, olanzapine (Zyprexa).

In a trial funded by the drug’s maker, Eli Lilly, 16 anorexia patients were randomized to outpatient day treatment plus olanzapine, and 18 to day treatment plus placebo.

The mean body mass index was low-normal in both groups at the end of 13 weeks (19.66 kg/m2 in the placebo group vs. 20.30 in the olanzapine group). However, placebo patients started with a lower mean BMI of 15.93, compared with 16.39 among olanzapine patients.

Also, at week 13, 55.6% of placebo patients but 87.5% of olanzapine patients achieved the target BMI of 18.5 (Am. J. Psychiatry 2008;165:1281-8).

The differences were "not very dramatic," but were statistically significant, Dr. Strober said.

"We have no idea what the mechanism is. We don’t know if it’s mediated by improved psychological state or weight gain associated with olanzapine," he said.

Given the lack of data, Dr. Strober said that he and his colleagues typically refeed anorexia inpatients for a few weeks, and only then add atypical antipsychotics if they aren’t managing well.

"I generally think [they] have more of an effect than the SSRIs, although we have patients receiving SSRIs who report less anxiety and psychological discomfort with weight gain," Dr. Strober said.

In general, however, "I have never seen a robust clinical effect of these agents," he said.

For bulimia, antidepressants have been shown to help.

"Regardless of the antidepressant used, in the majority of published studies – we really don’t know how many unpublished studies have been buried – active drug separates from placebo," Dr. Strober said.

"What this means is that about 60%-65% of people randomized to active treatment report a response (defined as a 50% or greater reduction in the frequency of binge eating)," compared with placebo responses of about 35%-40%, he said.

"We get remission rates – which means no bingeing or purging the last 2 weeks of the trial – of about 10% on active drug, maybe 0%-3% on placebo," he said.

However, about 50% of responders "have a recurrence of their symptoms" within 5 months, "so these are not very effective drugs for the majority of patients," Dr. Strober said.

CBT does better: "After 12-16 weeks, we get response rates (defined in the same way) that are roughly 65%-70%. You get about 35%-38% that are fully remitted, and that response tends to be more durable," he said.

Evidence also supports family-based therapy (FBT) for anorexia nervosa.

In a recent study, 121 subjects aged 12-18 years with mild to moderate illness – the trial excluded patients below 75% of their ideal body weight – were randomized to either individual therapy or FBT.

At the end of treatment and at 12 months’ follow-up, body weights were normal in about half of FBT patients but only in about a quarter of individual therapy patients (Arch. Gen. Psychiatry 2010;67:1025-32).

"There’s a signal here, I think – a powerful signal," Dr. Strober said. "This is a meaningful difference."

Family-based therapy "is an important treatment. We don’t really know what the ingredient is; we just know that this has been helpful for a number of families, but you really have to be very skilled in working with these people," he said.

Dr. Strober said he has no disclosures.

LOS ANGELES – Psychiatrists need to find a better diagnostic home for children who have explosive outbursts, according to Dr. Gabrielle A. Carlson.

They happen in children with all kinds of psychiatric diagnoses, but no good diagnostic description captures the pervasiveness of the problem, said Dr. Carlson, director of child and adolescent psychiatry at Stony Brook (N.Y.) University.

In some places, explosive outbursts earn children diagnoses of bipolar disorder, though they might otherwise lack classic symptoms.

And although some explosive children meet the criteria for temper dysregulation disorder with dysphoria (TDD), a diagnosis being considered for the DSM-5 ("New Pediatric Diagnoses Proposed for DSM-5," Clinical Psychiatry News, December 2010, p. 1), TDD would exclude children with many common psychiatric problems, including autism, depression, and posttraumatic stress disorder, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Children with these common diagnoses can have rages, too. "What about those kids?" she asked.

Intermittent explosive disorder isn’t a good fit, either, because it requires the absence of other psychiatric disorders, she said.

Modifying the Problem

Finding a diagnostic home for kids with explosive anger is more than an academic concern.

It matters because "explosive outbursts are the most serious, compelling problem we have in child psychiatry," often the reason why children are institutionalized, Dr. Carlson said.

"Until we’ve got a good label for [the problem], we are not going to have the [Food and Drug Administration] going after the indication; we are not going to have grants from the [National Institute of Mental Health] studying it," she said.

Dr. Carlson said she believes the solution is including a "with explosive outbursts" modifier in the DSM-5 to add to comorbid conditions such as attention-deficit/hyperactivity disorder. But the idea is not likely to make it into the upcoming version of the diagnostic manual. Dr. Carlson said she has been told by those involved in the revision that such a modifier would likely go unused by clinicians.

She proposed the idea to Dr. David Shaffer, the Columbia University professor of child psychiatry who serves as head of the DSM-5 childhood disruptive disorder work group.

In an interview, Dr. Shaffer confirmed that Dr. Carlson had, indeed, proposed the idea in an e-mail. In general, modifiers "come to be seen as subsidiary or a consequence to the parent diagnosis," he said in response to Dr. Carlson. "You then get into the whole causality ... debate which is a guaranteed way to undermine a diagnostic system. While we can usually agree on what we see, it is hard for us to agree on cause," he wrote. The modifier also would "end up littering the system with a host of specifiers," he added.

Complexity is "one of the factors that has been shown to reduce the reliability of a classification system. One of the goals for ... DSM-5 is to reduce the number of codes available," explained Dr. Shaffer, who also serves as chief of the division of psychiatry at Columbia University, New York. Meanwhile, in one of her responses, Dr. Carlson countered that "with explosives outbursts" wouldn’t be a new code, simply a modifier for existing conditions.

A Robust Effect for Stimulants

Though explosive outbursts occur in many disorders, they are most common in severe ADHD, oppositional-defiant disorder, and learning and language disorders, Dr. Carlson said. A thorough diagnostic work-up is needed to pinpoint their underlying cause so treatment can be provided. Behavior modification can help when the cause is ADHD; cognitive-behavioral therapy, when it’s depression. Social skills and language training help in autism.

Drugs have their place, too, but the target of drug therapy shifts to the outbursts themselves if treatment of their underlying cause fails. Lithium and divalproex have modest effect sizes for aggression in children, in the 0.3 range; effect sizes hover around 0.5 for alpha-agonists and 0.7 for atypical antipsychotics, Dr. Carlson said. Stimulants have the largest effect sizes, about 0.8, perhaps because ADHD is common in children with explosive outbursts, she said.

Dr. Carlson said she is concerned that the ADHD connection will be masked by a diagnosis of TDD, should TDD make it into DSM-5. "You’re going to forget these explosive kids [often] have ADHD, and will not use ADHD medication. That’s too bad; the effect size is 0.8," she said.

With drug treatment, "you need to keep the person on it for a while. You’re going to get some improvement, but it isn’t going to clean up nicely. It’s probably a good thing to warn people we can’t always do that," she noted.

Dr. Carlson said she is an adviser to Eli Lilly & Co., and receives research funding from Bristol-Myers Squibb and GlaxoSmithKline.

LOS ANGELES – Psychiatrists need to find a better diagnostic home for children who have explosive outbursts, according to Dr. Gabrielle A. Carlson.

They happen in children with all kinds of psychiatric diagnoses, but no good diagnostic description captures the pervasiveness of the problem, said Dr. Carlson, director of child and adolescent psychiatry at Stony Brook (N.Y.) University.

In some places, explosive outbursts earn children diagnoses of bipolar disorder, though they might otherwise lack classic symptoms.

And although some explosive children meet the criteria for temper dysregulation disorder with dysphoria (TDD), a diagnosis being considered for the DSM-5 ("New Pediatric Diagnoses Proposed for DSM-5," Clinical Psychiatry News, December 2010, p. 1), TDD would exclude children with many common psychiatric problems, including autism, depression, and posttraumatic stress disorder, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Children with these common diagnoses can have rages, too. "What about those kids?" she asked.

Intermittent explosive disorder isn’t a good fit, either, because it requires the absence of other psychiatric disorders, she said.

Modifying the Problem

Finding a diagnostic home for kids with explosive anger is more than an academic concern.

It matters because "explosive outbursts are the most serious, compelling problem we have in child psychiatry," often the reason why children are institutionalized, Dr. Carlson said.

"Until we’ve got a good label for [the problem], we are not going to have the [Food and Drug Administration] going after the indication; we are not going to have grants from the [National Institute of Mental Health] studying it," she said.

Dr. Carlson said she believes the solution is including a "with explosive outbursts" modifier in the DSM-5 to add to comorbid conditions such as attention-deficit/hyperactivity disorder. But the idea is not likely to make it into the upcoming version of the diagnostic manual. Dr. Carlson said she has been told by those involved in the revision that such a modifier would likely go unused by clinicians.

She proposed the idea to Dr. David Shaffer, the Columbia University professor of child psychiatry who serves as head of the DSM-5 childhood disruptive disorder work group.

In an interview, Dr. Shaffer confirmed that Dr. Carlson had, indeed, proposed the idea in an e-mail. In general, modifiers "come to be seen as subsidiary or a consequence to the parent diagnosis," he said in response to Dr. Carlson. "You then get into the whole causality ... debate which is a guaranteed way to undermine a diagnostic system. While we can usually agree on what we see, it is hard for us to agree on cause," he wrote. The modifier also would "end up littering the system with a host of specifiers," he added.

Complexity is "one of the factors that has been shown to reduce the reliability of a classification system. One of the goals for ... DSM-5 is to reduce the number of codes available," explained Dr. Shaffer, who also serves as chief of the division of psychiatry at Columbia University, New York. Meanwhile, in one of her responses, Dr. Carlson countered that "with explosives outbursts" wouldn’t be a new code, simply a modifier for existing conditions.

A Robust Effect for Stimulants

Though explosive outbursts occur in many disorders, they are most common in severe ADHD, oppositional-defiant disorder, and learning and language disorders, Dr. Carlson said. A thorough diagnostic work-up is needed to pinpoint their underlying cause so treatment can be provided. Behavior modification can help when the cause is ADHD; cognitive-behavioral therapy, when it’s depression. Social skills and language training help in autism.

Drugs have their place, too, but the target of drug therapy shifts to the outbursts themselves if treatment of their underlying cause fails. Lithium and divalproex have modest effect sizes for aggression in children, in the 0.3 range; effect sizes hover around 0.5 for alpha-agonists and 0.7 for atypical antipsychotics, Dr. Carlson said. Stimulants have the largest effect sizes, about 0.8, perhaps because ADHD is common in children with explosive outbursts, she said.

Dr. Carlson said she is concerned that the ADHD connection will be masked by a diagnosis of TDD, should TDD make it into DSM-5. "You’re going to forget these explosive kids [often] have ADHD, and will not use ADHD medication. That’s too bad; the effect size is 0.8," she said.

With drug treatment, "you need to keep the person on it for a while. You’re going to get some improvement, but it isn’t going to clean up nicely. It’s probably a good thing to warn people we can’t always do that," she noted.

Dr. Carlson said she is an adviser to Eli Lilly & Co., and receives research funding from Bristol-Myers Squibb and GlaxoSmithKline.

LOS ANGELES – Psychiatrists need to find a better diagnostic home for children who have explosive outbursts, according to Dr. Gabrielle A. Carlson.

They happen in children with all kinds of psychiatric diagnoses, but no good diagnostic description captures the pervasiveness of the problem, said Dr. Carlson, director of child and adolescent psychiatry at Stony Brook (N.Y.) University.

In some places, explosive outbursts earn children diagnoses of bipolar disorder, though they might otherwise lack classic symptoms.

And although some explosive children meet the criteria for temper dysregulation disorder with dysphoria (TDD), a diagnosis being considered for the DSM-5 ("New Pediatric Diagnoses Proposed for DSM-5," Clinical Psychiatry News, December 2010, p. 1), TDD would exclude children with many common psychiatric problems, including autism, depression, and posttraumatic stress disorder, Dr. Carlson said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Children with these common diagnoses can have rages, too. "What about those kids?" she asked.

Intermittent explosive disorder isn’t a good fit, either, because it requires the absence of other psychiatric disorders, she said.

Modifying the Problem

Finding a diagnostic home for kids with explosive anger is more than an academic concern.

It matters because "explosive outbursts are the most serious, compelling problem we have in child psychiatry," often the reason why children are institutionalized, Dr. Carlson said.

"Until we’ve got a good label for [the problem], we are not going to have the [Food and Drug Administration] going after the indication; we are not going to have grants from the [National Institute of Mental Health] studying it," she said.

Dr. Carlson said she believes the solution is including a "with explosive outbursts" modifier in the DSM-5 to add to comorbid conditions such as attention-deficit/hyperactivity disorder. But the idea is not likely to make it into the upcoming version of the diagnostic manual. Dr. Carlson said she has been told by those involved in the revision that such a modifier would likely go unused by clinicians.

She proposed the idea to Dr. David Shaffer, the Columbia University professor of child psychiatry who serves as head of the DSM-5 childhood disruptive disorder work group.

In an interview, Dr. Shaffer confirmed that Dr. Carlson had, indeed, proposed the idea in an e-mail. In general, modifiers "come to be seen as subsidiary or a consequence to the parent diagnosis," he said in response to Dr. Carlson. "You then get into the whole causality ... debate which is a guaranteed way to undermine a diagnostic system. While we can usually agree on what we see, it is hard for us to agree on cause," he wrote. The modifier also would "end up littering the system with a host of specifiers," he added.

Complexity is "one of the factors that has been shown to reduce the reliability of a classification system. One of the goals for ... DSM-5 is to reduce the number of codes available," explained Dr. Shaffer, who also serves as chief of the division of psychiatry at Columbia University, New York. Meanwhile, in one of her responses, Dr. Carlson countered that "with explosives outbursts" wouldn’t be a new code, simply a modifier for existing conditions.

A Robust Effect for Stimulants

Though explosive outbursts occur in many disorders, they are most common in severe ADHD, oppositional-defiant disorder, and learning and language disorders, Dr. Carlson said. A thorough diagnostic work-up is needed to pinpoint their underlying cause so treatment can be provided. Behavior modification can help when the cause is ADHD; cognitive-behavioral therapy, when it’s depression. Social skills and language training help in autism.

Drugs have their place, too, but the target of drug therapy shifts to the outbursts themselves if treatment of their underlying cause fails. Lithium and divalproex have modest effect sizes for aggression in children, in the 0.3 range; effect sizes hover around 0.5 for alpha-agonists and 0.7 for atypical antipsychotics, Dr. Carlson said. Stimulants have the largest effect sizes, about 0.8, perhaps because ADHD is common in children with explosive outbursts, she said.

Dr. Carlson said she is concerned that the ADHD connection will be masked by a diagnosis of TDD, should TDD make it into DSM-5. "You’re going to forget these explosive kids [often] have ADHD, and will not use ADHD medication. That’s too bad; the effect size is 0.8," she said.

With drug treatment, "you need to keep the person on it for a while. You’re going to get some improvement, but it isn’t going to clean up nicely. It’s probably a good thing to warn people we can’t always do that," she noted.

Dr. Carlson said she is an adviser to Eli Lilly & Co., and receives research funding from Bristol-Myers Squibb and GlaxoSmithKline.

LOS ANGELES – Sometimes, it’s possible to bring an end to tics without drugs.

Habit reversal training (HRT), a behavioral tic treatment, is not only a useful medication adjunct, but can sometimes prove to be the better first-line option, Dr. James T. McCracken said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry.

"This is an interesting and potentially very important treatment," said Dr. McCracken, director of the division of child and adolescent psychiatry at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

First, the patient is made aware of his tic in one or two treatment sessions; tic counting and other exercises help, Dr. McCracken said.

The premonitory urge is addressed next. A patient who cannot stop flashing his middle finger, for instance, might describe an initial tingling in the hand, or maybe the shoulder.

The patient is then taught a competing response for the urge. The middle-finger flasher might straighten his arm or grab the offending hand until the urge fades.

Meanwhile, the therapist addresses environmental triggers; anxious parents might be told, for instance, to stop fussing about the tic.

In short, "if you’ve got somebody [who is] really working with you and practices, you can knock out a tic in about maybe one or two sessions," Dr. McCracken said.

Phonic tics and dominant motor tics respond especially well. "You can really [target them] with behavioral intervention," he said.

In a recent study of children with Tourette’s syndrome or chronic tic disorder, HRT substantially reduced tics in 32 out of 61 children after 10 weeks, a response rate above 50%. Benefits remained durable at 6-month follow-up (JAMA 2010;303:1929-37).

"By no means does [HRT] propose to replace medication treatment," Dr. McCracken said. About half of the kids in the trial were on alpha-agonists, antipsychotics, or other medications.

But "I think it can be a very useful adjunct for some, where the degree of tic control is just falling short," and "it might be a good place to start if you gain confidence with this approach," he said.

Several manuals teach the technique, and the Tourette Syndrome Association offers training, he said.

The Big Guns

Dr. McCracken said it’s sometimes best to wait before starting medications.

Tics ebb and flow, and are often driven by anxiety-provoking – and temporary – life-changes, like the start of the school year.

"Because this disorder occurs in bouts, you want to wait it out for at least a couple of weeks, assuming you’re not looking at eye-gouging tics or something else of major concern," he said.

When watchful waiting doesn’t do the trick, however, "our big guns for treating tics are the antipsychotics," Dr. McCracken said.

Haloperidol and pimozide "certainly work. Risperidone and ziprasidone have their own controlled trials as well," he said.

He starts with a low dose – about 3 or 4 mg/day – and titrates up slowly to avoid side effects, adding no more than a milligram a week.

"I often stretch it out longer than that," Dr. McCracken said.

In general, antipsychotics reduce tics by about 40%.

Because of that, "I caution parents from the get-go [to] not expect the tics to go away. Our goal is to reduce the impairment," he said.

Pimozide has been associated with lethal arrhythmias at doses of about 10 mg. Though tic control doesn’t usually require high doses, an ECG is a smart move when they do, he said.

Alpha-agonists are an option before bringing out the big guns, with some evidence supporting both clonidine and guanfacine. Adding an alpha-agonist to an antipsychotic also can "be enough to knock out a tic substantially," he said.

Antibiotics? Maybe

For most children, a comorbid problem – typically attention-deficit/hyperactivity disorder –causes more impairment than their tic.

When ADHD is the main problem, "I think the consensus is that stimulants can be used cautiously," Dr. McCracken said.

Methylphenidate and clonidine together, for instance, have been shown to both help ADHD and control tics (Neurology2002;58:527-36).

Dr. McCracken said he prefers the immediate-release type, when stimulants are used.

"I have found some kids who are very sensitive to stimulant-induced tic-worsening can get by with adding in a stimulant during the day just when they need it, really trying to minimize that exposure," he said.

Group A streptococcal infections have been associated with new-onset tics, which suggests that may be a role for antibiotics in tic treatment, as well. "Continuing the antibiotics may reduce the incidence of subsequent relapse, but that is not so firmly established. Beta-lactam antibiotics, which include amoxicillin and cephalosporins, seem to be most useful. [Try] standard treatments first, though," Dr. McCracken said.

Dr. McCracken said he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from Bristol-Myers Squibb and Seaside Pharmaceutical.

LOS ANGELES – Sometimes, it’s possible to bring an end to tics without drugs.

Habit reversal training (HRT), a behavioral tic treatment, is not only a useful medication adjunct, but can sometimes prove to be the better first-line option, Dr. James T. McCracken said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry.

"This is an interesting and potentially very important treatment," said Dr. McCracken, director of the division of child and adolescent psychiatry at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

First, the patient is made aware of his tic in one or two treatment sessions; tic counting and other exercises help, Dr. McCracken said.

The premonitory urge is addressed next. A patient who cannot stop flashing his middle finger, for instance, might describe an initial tingling in the hand, or maybe the shoulder.

The patient is then taught a competing response for the urge. The middle-finger flasher might straighten his arm or grab the offending hand until the urge fades.

Meanwhile, the therapist addresses environmental triggers; anxious parents might be told, for instance, to stop fussing about the tic.

In short, "if you’ve got somebody [who is] really working with you and practices, you can knock out a tic in about maybe one or two sessions," Dr. McCracken said.

Phonic tics and dominant motor tics respond especially well. "You can really [target them] with behavioral intervention," he said.

In a recent study of children with Tourette’s syndrome or chronic tic disorder, HRT substantially reduced tics in 32 out of 61 children after 10 weeks, a response rate above 50%. Benefits remained durable at 6-month follow-up (JAMA 2010;303:1929-37).

"By no means does [HRT] propose to replace medication treatment," Dr. McCracken said. About half of the kids in the trial were on alpha-agonists, antipsychotics, or other medications.

But "I think it can be a very useful adjunct for some, where the degree of tic control is just falling short," and "it might be a good place to start if you gain confidence with this approach," he said.

Several manuals teach the technique, and the Tourette Syndrome Association offers training, he said.

The Big Guns

Dr. McCracken said it’s sometimes best to wait before starting medications.

Tics ebb and flow, and are often driven by anxiety-provoking – and temporary – life-changes, like the start of the school year.

"Because this disorder occurs in bouts, you want to wait it out for at least a couple of weeks, assuming you’re not looking at eye-gouging tics or something else of major concern," he said.

When watchful waiting doesn’t do the trick, however, "our big guns for treating tics are the antipsychotics," Dr. McCracken said.

Haloperidol and pimozide "certainly work. Risperidone and ziprasidone have their own controlled trials as well," he said.

He starts with a low dose – about 3 or 4 mg/day – and titrates up slowly to avoid side effects, adding no more than a milligram a week.

"I often stretch it out longer than that," Dr. McCracken said.

In general, antipsychotics reduce tics by about 40%.

Because of that, "I caution parents from the get-go [to] not expect the tics to go away. Our goal is to reduce the impairment," he said.

Pimozide has been associated with lethal arrhythmias at doses of about 10 mg. Though tic control doesn’t usually require high doses, an ECG is a smart move when they do, he said.

Alpha-agonists are an option before bringing out the big guns, with some evidence supporting both clonidine and guanfacine. Adding an alpha-agonist to an antipsychotic also can "be enough to knock out a tic substantially," he said.

Antibiotics? Maybe

For most children, a comorbid problem – typically attention-deficit/hyperactivity disorder –causes more impairment than their tic.

When ADHD is the main problem, "I think the consensus is that stimulants can be used cautiously," Dr. McCracken said.

Methylphenidate and clonidine together, for instance, have been shown to both help ADHD and control tics (Neurology2002;58:527-36).

Dr. McCracken said he prefers the immediate-release type, when stimulants are used.

"I have found some kids who are very sensitive to stimulant-induced tic-worsening can get by with adding in a stimulant during the day just when they need it, really trying to minimize that exposure," he said.

Group A streptococcal infections have been associated with new-onset tics, which suggests that may be a role for antibiotics in tic treatment, as well. "Continuing the antibiotics may reduce the incidence of subsequent relapse, but that is not so firmly established. Beta-lactam antibiotics, which include amoxicillin and cephalosporins, seem to be most useful. [Try] standard treatments first, though," Dr. McCracken said.

Dr. McCracken said he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from Bristol-Myers Squibb and Seaside Pharmaceutical.

LOS ANGELES – Sometimes, it’s possible to bring an end to tics without drugs.

Habit reversal training (HRT), a behavioral tic treatment, is not only a useful medication adjunct, but can sometimes prove to be the better first-line option, Dr. James T. McCracken said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry.

"This is an interesting and potentially very important treatment," said Dr. McCracken, director of the division of child and adolescent psychiatry at the University of California, Los Angeles, Semel Institute for Neuroscience and Human Behavior.

First, the patient is made aware of his tic in one or two treatment sessions; tic counting and other exercises help, Dr. McCracken said.

The premonitory urge is addressed next. A patient who cannot stop flashing his middle finger, for instance, might describe an initial tingling in the hand, or maybe the shoulder.

The patient is then taught a competing response for the urge. The middle-finger flasher might straighten his arm or grab the offending hand until the urge fades.

Meanwhile, the therapist addresses environmental triggers; anxious parents might be told, for instance, to stop fussing about the tic.

In short, "if you’ve got somebody [who is] really working with you and practices, you can knock out a tic in about maybe one or two sessions," Dr. McCracken said.

Phonic tics and dominant motor tics respond especially well. "You can really [target them] with behavioral intervention," he said.

In a recent study of children with Tourette’s syndrome or chronic tic disorder, HRT substantially reduced tics in 32 out of 61 children after 10 weeks, a response rate above 50%. Benefits remained durable at 6-month follow-up (JAMA 2010;303:1929-37).

"By no means does [HRT] propose to replace medication treatment," Dr. McCracken said. About half of the kids in the trial were on alpha-agonists, antipsychotics, or other medications.

But "I think it can be a very useful adjunct for some, where the degree of tic control is just falling short," and "it might be a good place to start if you gain confidence with this approach," he said.

Several manuals teach the technique, and the Tourette Syndrome Association offers training, he said.

The Big Guns

Dr. McCracken said it’s sometimes best to wait before starting medications.

Tics ebb and flow, and are often driven by anxiety-provoking – and temporary – life-changes, like the start of the school year.

"Because this disorder occurs in bouts, you want to wait it out for at least a couple of weeks, assuming you’re not looking at eye-gouging tics or something else of major concern," he said.

When watchful waiting doesn’t do the trick, however, "our big guns for treating tics are the antipsychotics," Dr. McCracken said.

Haloperidol and pimozide "certainly work. Risperidone and ziprasidone have their own controlled trials as well," he said.

He starts with a low dose – about 3 or 4 mg/day – and titrates up slowly to avoid side effects, adding no more than a milligram a week.

"I often stretch it out longer than that," Dr. McCracken said.

In general, antipsychotics reduce tics by about 40%.

Because of that, "I caution parents from the get-go [to] not expect the tics to go away. Our goal is to reduce the impairment," he said.

Pimozide has been associated with lethal arrhythmias at doses of about 10 mg. Though tic control doesn’t usually require high doses, an ECG is a smart move when they do, he said.

Alpha-agonists are an option before bringing out the big guns, with some evidence supporting both clonidine and guanfacine. Adding an alpha-agonist to an antipsychotic also can "be enough to knock out a tic substantially," he said.

Antibiotics? Maybe

For most children, a comorbid problem – typically attention-deficit/hyperactivity disorder –causes more impairment than their tic.

When ADHD is the main problem, "I think the consensus is that stimulants can be used cautiously," Dr. McCracken said.

Methylphenidate and clonidine together, for instance, have been shown to both help ADHD and control tics (Neurology2002;58:527-36).

Dr. McCracken said he prefers the immediate-release type, when stimulants are used.

"I have found some kids who are very sensitive to stimulant-induced tic-worsening can get by with adding in a stimulant during the day just when they need it, really trying to minimize that exposure," he said.

Group A streptococcal infections have been associated with new-onset tics, which suggests that may be a role for antibiotics in tic treatment, as well. "Continuing the antibiotics may reduce the incidence of subsequent relapse, but that is not so firmly established. Beta-lactam antibiotics, which include amoxicillin and cephalosporins, seem to be most useful. [Try] standard treatments first, though," Dr. McCracken said.

Dr. McCracken said he is an adviser to BioMarin Pharmaceutical Inc., and receives research funding from Bristol-Myers Squibb and Seaside Pharmaceutical.

SAN ANTONIO — When diabetes patients team up as mentors and mentees – with one coaching the other on how to best control the disease – a curious thing happens: Not only do those being coached do better, but the patients doing the coaching do better as well.

Mutual accountability is the reason, said Dr. Robin Eickhoff, a family physician helping pilot the technique at WellMed, a San Antonio–based company specializing in medical care for people aged 65 years and over.

Mentors think, “If I am going to try to teach you to be a better diabetic, I should sing the same tune” as a role model, Dr. Eickhoff said during an interview. Mentors and mentees “tend to hold each other accountable. There's a certain accountability you have when you are working with somebody and setting goals,” she said.

In a project funded by an American Academy of Family Physicians grant, WellMed has paired 41 mentors with 113 mentees at 15 of its clinics since late 2009.

Dr. Eickhoff explained that the idea sprang from the work of Dr. America Bracho, who has successfully used peer mentors at Latino Health Access in Orange County, Calif.

Patients at WellMed were paired up after they completed an 8-week introduction to diabetes course that instructed them about medications, blood glucose monitoring, and healthy meal planning, among other things. By the end of November 2010, 246 patients had completed the course.

Although WellMed has only preliminary data on its peer-mentoring efforts, the results appear to show benefit for mentee and mentor alike.

For instance, before the diabetes course, patients tested their blood sugar 4.4 times per week. After the class and 6 months of mentor-mentee partnerships, mentees reported checking an average of 6.5 times per week, while mentors checked 5.2 times. Compared with how they were doing before the course, mentors and mentees reported improved hemoglobin A_1c levels, exercising more, and eating less fat and more fruits and vegetables.

WellMed educators look for potential mentors during the diabetes introductory course, taking note of good listeners with a willingness to learn, Dr. Eickhoff said. Those selected get additional guidance on how to talk to other patients, and are then matched with mentees from similar backgrounds whose lab values indicate they need extra diabetes help.

Most patients accept the invitation to be mentors, Dr. Eickhoff said at the meeting, cosponsored by the Society of Teachers of Family Medicine and the AAFP.

The initial mentor-mentee meetings were at WellMed's monthly diabetes group meetings, so they could be supervised. WellMed staff wanted to ensure that mentors gave sound advice and that the relationships worked. Rarely, there were problems, as when a mentor mentioned that she'd stopped taking her diabetes medications and was doing fine on dietary supplements.

After the kinks are worked out, the relationships blossom. “We have seen so much positive feedback from both the mentors and the mentees,” Dr. Eickhoff said. “The enthusiasm from patients has been huge.”

Mentors and mentees interact at least 4 hours per month, part of it at the group meetings, and the rest by phone, over lunch, or however else they chose to interact, Dr. Eickhoff said. They might brainstorm problems together, give each other emotional support, share recipes, and compare lab values, among other things.

For example, one woman's family did not want to give up its high-fat, high-carbohydrate diet, including mashed potatoes. Her mentor suggested mashed cauliflower; the family didn't' even notice the switch, Dr. Eickhoff said.

Another woman, unable to go grocery shopping, felt she had no control over what her daughter brought back to the house. Her mentor suggested giving the daughter a weekly shopping list. It helped.

“They tell each other things that they don't tell us as providers, but will share with someone in a similar situation,” Dr. Eickhoff said. Plus, physicians “don't necessarily have time to delve into [patients'] day-to-day lives, yet so much of their diet and their lifestyle are affected by their social [situations].

“Mentors have the ability to talk about those things, because they've been through it,” she said.

SAN ANTONIO — When diabetes patients team up as mentors and mentees – with one coaching the other on how to best control the disease – a curious thing happens: Not only do those being coached do better, but the patients doing the coaching do better as well.

Mutual accountability is the reason, said Dr. Robin Eickhoff, a family physician helping pilot the technique at WellMed, a San Antonio–based company specializing in medical care for people aged 65 years and over.

Mentors think, “If I am going to try to teach you to be a better diabetic, I should sing the same tune” as a role model, Dr. Eickhoff said during an interview. Mentors and mentees “tend to hold each other accountable. There's a certain accountability you have when you are working with somebody and setting goals,” she said.

In a project funded by an American Academy of Family Physicians grant, WellMed has paired 41 mentors with 113 mentees at 15 of its clinics since late 2009.

Dr. Eickhoff explained that the idea sprang from the work of Dr. America Bracho, who has successfully used peer mentors at Latino Health Access in Orange County, Calif.

Patients at WellMed were paired up after they completed an 8-week introduction to diabetes course that instructed them about medications, blood glucose monitoring, and healthy meal planning, among other things. By the end of November 2010, 246 patients had completed the course.

Although WellMed has only preliminary data on its peer-mentoring efforts, the results appear to show benefit for mentee and mentor alike.

For instance, before the diabetes course, patients tested their blood sugar 4.4 times per week. After the class and 6 months of mentor-mentee partnerships, mentees reported checking an average of 6.5 times per week, while mentors checked 5.2 times. Compared with how they were doing before the course, mentors and mentees reported improved hemoglobin A_1c levels, exercising more, and eating less fat and more fruits and vegetables.

WellMed educators look for potential mentors during the diabetes introductory course, taking note of good listeners with a willingness to learn, Dr. Eickhoff said. Those selected get additional guidance on how to talk to other patients, and are then matched with mentees from similar backgrounds whose lab values indicate they need extra diabetes help.

Most patients accept the invitation to be mentors, Dr. Eickhoff said at the meeting, cosponsored by the Society of Teachers of Family Medicine and the AAFP.

The initial mentor-mentee meetings were at WellMed's monthly diabetes group meetings, so they could be supervised. WellMed staff wanted to ensure that mentors gave sound advice and that the relationships worked. Rarely, there were problems, as when a mentor mentioned that she'd stopped taking her diabetes medications and was doing fine on dietary supplements.

After the kinks are worked out, the relationships blossom. “We have seen so much positive feedback from both the mentors and the mentees,” Dr. Eickhoff said. “The enthusiasm from patients has been huge.”

Mentors and mentees interact at least 4 hours per month, part of it at the group meetings, and the rest by phone, over lunch, or however else they chose to interact, Dr. Eickhoff said. They might brainstorm problems together, give each other emotional support, share recipes, and compare lab values, among other things.

For example, one woman's family did not want to give up its high-fat, high-carbohydrate diet, including mashed potatoes. Her mentor suggested mashed cauliflower; the family didn't' even notice the switch, Dr. Eickhoff said.

Another woman, unable to go grocery shopping, felt she had no control over what her daughter brought back to the house. Her mentor suggested giving the daughter a weekly shopping list. It helped.

“They tell each other things that they don't tell us as providers, but will share with someone in a similar situation,” Dr. Eickhoff said. Plus, physicians “don't necessarily have time to delve into [patients'] day-to-day lives, yet so much of their diet and their lifestyle are affected by their social [situations].

“Mentors have the ability to talk about those things, because they've been through it,” she said.

SAN ANTONIO — When diabetes patients team up as mentors and mentees – with one coaching the other on how to best control the disease – a curious thing happens: Not only do those being coached do better, but the patients doing the coaching do better as well.

Mutual accountability is the reason, said Dr. Robin Eickhoff, a family physician helping pilot the technique at WellMed, a San Antonio–based company specializing in medical care for people aged 65 years and over.

Mentors think, “If I am going to try to teach you to be a better diabetic, I should sing the same tune” as a role model, Dr. Eickhoff said during an interview. Mentors and mentees “tend to hold each other accountable. There's a certain accountability you have when you are working with somebody and setting goals,” she said.

In a project funded by an American Academy of Family Physicians grant, WellMed has paired 41 mentors with 113 mentees at 15 of its clinics since late 2009.

Dr. Eickhoff explained that the idea sprang from the work of Dr. America Bracho, who has successfully used peer mentors at Latino Health Access in Orange County, Calif.

Patients at WellMed were paired up after they completed an 8-week introduction to diabetes course that instructed them about medications, blood glucose monitoring, and healthy meal planning, among other things. By the end of November 2010, 246 patients had completed the course.

Although WellMed has only preliminary data on its peer-mentoring efforts, the results appear to show benefit for mentee and mentor alike.

For instance, before the diabetes course, patients tested their blood sugar 4.4 times per week. After the class and 6 months of mentor-mentee partnerships, mentees reported checking an average of 6.5 times per week, while mentors checked 5.2 times. Compared with how they were doing before the course, mentors and mentees reported improved hemoglobin A_1c levels, exercising more, and eating less fat and more fruits and vegetables.

WellMed educators look for potential mentors during the diabetes introductory course, taking note of good listeners with a willingness to learn, Dr. Eickhoff said. Those selected get additional guidance on how to talk to other patients, and are then matched with mentees from similar backgrounds whose lab values indicate they need extra diabetes help.

Most patients accept the invitation to be mentors, Dr. Eickhoff said at the meeting, cosponsored by the Society of Teachers of Family Medicine and the AAFP.

The initial mentor-mentee meetings were at WellMed's monthly diabetes group meetings, so they could be supervised. WellMed staff wanted to ensure that mentors gave sound advice and that the relationships worked. Rarely, there were problems, as when a mentor mentioned that she'd stopped taking her diabetes medications and was doing fine on dietary supplements.

After the kinks are worked out, the relationships blossom. “We have seen so much positive feedback from both the mentors and the mentees,” Dr. Eickhoff said. “The enthusiasm from patients has been huge.”

Mentors and mentees interact at least 4 hours per month, part of it at the group meetings, and the rest by phone, over lunch, or however else they chose to interact, Dr. Eickhoff said. They might brainstorm problems together, give each other emotional support, share recipes, and compare lab values, among other things.

For example, one woman's family did not want to give up its high-fat, high-carbohydrate diet, including mashed potatoes. Her mentor suggested mashed cauliflower; the family didn't' even notice the switch, Dr. Eickhoff said.

Another woman, unable to go grocery shopping, felt she had no control over what her daughter brought back to the house. Her mentor suggested giving the daughter a weekly shopping list. It helped.

“They tell each other things that they don't tell us as providers, but will share with someone in a similar situation,” Dr. Eickhoff said. Plus, physicians “don't necessarily have time to delve into [patients'] day-to-day lives, yet so much of their diet and their lifestyle are affected by their social [situations].

“Mentors have the ability to talk about those things, because they've been through it,” she said.

SAN ANTONIO — When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that's what happened at the Cabarrus Family Medicine clinic in Concord, N.C., according to Sandy Robertson, a Cabarrus Pharm.D.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus's residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic's electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A_1c values above 9%. Dr. Robertson then asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

“I did a lot of listening. My job was to find out why they were having problems. I certainly didn't have a canned diabetes talk,” Dr. Robertson said. “Some patients didn't even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they're too hard,” she said.

In the latter cases, Dr. Robertson would say something like, “'Okay, let's make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you'll only eat half a bowl? I am going to try to negotiate with you.' They would respond to that,” she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, “'You're going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,'” she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn't have time for such hand holding, she said.

Her methods worked.

At the conference, sponsord by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their HbA_1c levels within the first 3 months. One patient's HbA_1c fell from 14% to 5.8%, another's from 11% to 7%, and a third's from 10.8% to 6.8%.

“We don't have enough data yet to do any kind of statistical analysis, [but] I feel really good about” the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients.

When Dr. Robertson's pilot project ended, Cabarrus hired another pharmacist to do similar work full time, and then another several months later.

Polled about the new pharmacist, 9 of the 12 doctors at the clinic strongly agreed that patients appreciated her attention and that she improved patients' medication knowledge, overall chronic disease management, and physicians' satisfaction in managing challenging patients.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. “We are billing what we can,” Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SAN ANTONIO — When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that's what happened at the Cabarrus Family Medicine clinic in Concord, N.C., according to Sandy Robertson, a Cabarrus Pharm.D.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus's residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic's electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A_1c values above 9%. Dr. Robertson then asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

“I did a lot of listening. My job was to find out why they were having problems. I certainly didn't have a canned diabetes talk,” Dr. Robertson said. “Some patients didn't even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they're too hard,” she said.

In the latter cases, Dr. Robertson would say something like, “'Okay, let's make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you'll only eat half a bowl? I am going to try to negotiate with you.' They would respond to that,” she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, “'You're going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,'” she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn't have time for such hand holding, she said.

Her methods worked.

At the conference, sponsord by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their HbA_1c levels within the first 3 months. One patient's HbA_1c fell from 14% to 5.8%, another's from 11% to 7%, and a third's from 10.8% to 6.8%.

“We don't have enough data yet to do any kind of statistical analysis, [but] I feel really good about” the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients.

When Dr. Robertson's pilot project ended, Cabarrus hired another pharmacist to do similar work full time, and then another several months later.

Polled about the new pharmacist, 9 of the 12 doctors at the clinic strongly agreed that patients appreciated her attention and that she improved patients' medication knowledge, overall chronic disease management, and physicians' satisfaction in managing challenging patients.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. “We are billing what we can,” Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SAN ANTONIO — When pharmacists enter the exam room to educate patients about diabetes, physicians save time and diabetes control improves.

At least that's what happened at the Cabarrus Family Medicine clinic in Concord, N.C., according to Sandy Robertson, a Cabarrus Pharm.D.

At a time when clinics across the country are adding pharmacists to patient-centered medical home teams, the Concord experience indicates what works, and what does not.

The story there began in July 2009, when Dr. Robertson volunteered to counsel patients on 2 half-days per week, taking time off from her usual teaching duties in Cabarrus's residency program. She and managers at the 11-clinic family medicine chain wanted to see if pharmacist counseling would improve care. Dr. Robertson worked primarily with diabetes patients, she said in an interview.

To prepare for the visits, she scanned the clinic's electronic health records to identify diabetic patients who needed extra help – those with hemoglobin A_1c values above 9%. Dr. Robertson then asked doctors to schedule her with struggling patients during upcoming visits. Patients, she found, were happy to talk so long as she was first introduced by a doctor. The initial visits almost always took a half hour or longer. Meanwhile, doctors would see other patients, popping back into the exam room in about 30 minutes.

“I did a lot of listening. My job was to find out why they were having problems. I certainly didn't have a canned diabetes talk,” Dr. Robertson said. “Some patients didn't even understand how to take their insulin, and asked me the most elementary questions. Some were well educated about their diabetes, but were choosing not to follow [recommendations] because they're too hard,” she said.

In the latter cases, Dr. Robertson would say something like, “'Okay, let's make a deal. Instead of eating a whole bowl of ice cream every night, will you shake my hand and promise me that you'll only eat half a bowl? I am going to try to negotiate with you.' They would respond to that,” she said.

Much of the time, Dr. Robertson was a cheerleader, telling patients, for instance, “'You're going to have to come back in 3 months and your numbers are going to be great, and your doctor is going to be so pleased with you,'” she said.

Dr. Robertson also called patients between visits to remind them of upcoming appointments, and to encourage them to take better care of themselves; physicians in Concord simply didn't have time for such hand holding, she said.

Her methods worked.

At the conference, sponsord by the Society of Teachers of Family Medicine, Dr. Robertson presented data from her 9 toughest patients out of the 130-plus she counseled. Each dropped their HbA_1c levels within the first 3 months. One patient's HbA_1c fell from 14% to 5.8%, another's from 11% to 7%, and a third's from 10.8% to 6.8%.

“We don't have enough data yet to do any kind of statistical analysis, [but] I feel really good about” the outcomes, she said. Physicians did, too. After a while, they were simply pulling Dr. Robertson into exam rooms to talk with newly diagnosed patients.

When Dr. Robertson's pilot project ended, Cabarrus hired another pharmacist to do similar work full time, and then another several months later.

Polled about the new pharmacist, 9 of the 12 doctors at the clinic strongly agreed that patients appreciated her attention and that she improved patients' medication knowledge, overall chronic disease management, and physicians' satisfaction in managing challenging patients.

During her pilot project, Dr. Robertson was paid out of the residency program. The two new pharmacists are also on salary. Only about half of third-party payers are reimbursing their efforts – billed mostly as medication management – at about $35-$75 per half hour. “We are billing what we can,” Dr. Robertson said.

The conference was also sponsored by the American Academy of Family Physicians.

SEATTLE — True electronic health record interoperability, with seamless information transfer between systems made by different companies, is still years off, agreed panelists discussing health information technology.

They also agreed that when interoperability comes, it will quickly identify emerging public health problems, address outcomes disparities, and lead to new drugs and other treatments because connected systems will, in effect, function as a massive clinical database.

“We would be a failure as an industry if we weren't [eventually] able to find problems with chloromycetin and thalidomide [for example] much earlier” using the new technology, said Judith Faulkner, founder and CEO of the electronic health records (EHR) company Epic Systems. “I would hope we can focus on things such as autism and figure out the causes.”

The lack of EHR standardization stands in the way of such potential, panelists said. The tens of thousands of data elements in Epic's database are different from the elements in the Cerner database, which are different from those in the AllScripts database, said Peter Neupert, who is corporate vice president of Microsoft's health solutions group.

One of the reasons, he said, is that vendors have little economic incentive to share information and standardize their approaches.

If an interoperability solution is not found, however, “China's going to figure it out and export it here, or India is going to export it here,” said Mr. Neupert. Those countries are developing health information technology to sell at prices lower than U.S. developers' prices, he said.

Microsoft's HealthVault allows consumers to store health information online for quick access wherever they're treated, among other functions. Amalga, another Microsoft product, allows organizations to aggregate and mine clinical data.

Epic is developing Care Everywhere, a system to transfer medical records – with patients' consent – across different EHR systems.

It's also working on a Connect the Docs system to facilitate communication and expertise-sharing between physicians, Ms. Faulkner said.

The federal government is working on interoperability fixes, too, said panelists. The current incentives for physicians and hospitals to install EHR systems include the goal that they eventually will be interoperable.

Among other measures, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act funds the formation of regional health information repositories that can be queried by providers. The Office of the National Coordinator for Health Information Technology created by the act is developing a secure, e-mail–like system over which providers can exchange patients' medical information.

HITECH, however, “is a start, not a finish,” said Rep. Jay Inslee (D-Wash.), also a panelist. He agreed that the challenge remains in “making sure systems can work together.”

Mr. Neupert expressed confidence. “Computing is going to get 1,000 times faster in the next 10 years. With cheap storage and 1,000 times the processing power, we can translate stuff in Epic's data store [and] Cerner's data store and every other data store into a meaningful operational data asset. It's going to be really fabulous for individuals.”

SEATTLE — True electronic health record interoperability, with seamless information transfer between systems made by different companies, is still years off, agreed panelists discussing health information technology.

They also agreed that when interoperability comes, it will quickly identify emerging public health problems, address outcomes disparities, and lead to new drugs and other treatments because connected systems will, in effect, function as a massive clinical database.

“We would be a failure as an industry if we weren't [eventually] able to find problems with chloromycetin and thalidomide [for example] much earlier” using the new technology, said Judith Faulkner, founder and CEO of the electronic health records (EHR) company Epic Systems. “I would hope we can focus on things such as autism and figure out the causes.”

The lack of EHR standardization stands in the way of such potential, panelists said. The tens of thousands of data elements in Epic's database are different from the elements in the Cerner database, which are different from those in the AllScripts database, said Peter Neupert, who is corporate vice president of Microsoft's health solutions group.

One of the reasons, he said, is that vendors have little economic incentive to share information and standardize their approaches.

If an interoperability solution is not found, however, “China's going to figure it out and export it here, or India is going to export it here,” said Mr. Neupert. Those countries are developing health information technology to sell at prices lower than U.S. developers' prices, he said.

Microsoft's HealthVault allows consumers to store health information online for quick access wherever they're treated, among other functions. Amalga, another Microsoft product, allows organizations to aggregate and mine clinical data.

Epic is developing Care Everywhere, a system to transfer medical records – with patients' consent – across different EHR systems.

It's also working on a Connect the Docs system to facilitate communication and expertise-sharing between physicians, Ms. Faulkner said.

The federal government is working on interoperability fixes, too, said panelists. The current incentives for physicians and hospitals to install EHR systems include the goal that they eventually will be interoperable.

Among other measures, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act funds the formation of regional health information repositories that can be queried by providers. The Office of the National Coordinator for Health Information Technology created by the act is developing a secure, e-mail–like system over which providers can exchange patients' medical information.

HITECH, however, “is a start, not a finish,” said Rep. Jay Inslee (D-Wash.), also a panelist. He agreed that the challenge remains in “making sure systems can work together.”

Mr. Neupert expressed confidence. “Computing is going to get 1,000 times faster in the next 10 years. With cheap storage and 1,000 times the processing power, we can translate stuff in Epic's data store [and] Cerner's data store and every other data store into a meaningful operational data asset. It's going to be really fabulous for individuals.”

SEATTLE — True electronic health record interoperability, with seamless information transfer between systems made by different companies, is still years off, agreed panelists discussing health information technology.

They also agreed that when interoperability comes, it will quickly identify emerging public health problems, address outcomes disparities, and lead to new drugs and other treatments because connected systems will, in effect, function as a massive clinical database.

“We would be a failure as an industry if we weren't [eventually] able to find problems with chloromycetin and thalidomide [for example] much earlier” using the new technology, said Judith Faulkner, founder and CEO of the electronic health records (EHR) company Epic Systems. “I would hope we can focus on things such as autism and figure out the causes.”

The lack of EHR standardization stands in the way of such potential, panelists said. The tens of thousands of data elements in Epic's database are different from the elements in the Cerner database, which are different from those in the AllScripts database, said Peter Neupert, who is corporate vice president of Microsoft's health solutions group.

One of the reasons, he said, is that vendors have little economic incentive to share information and standardize their approaches.

If an interoperability solution is not found, however, “China's going to figure it out and export it here, or India is going to export it here,” said Mr. Neupert. Those countries are developing health information technology to sell at prices lower than U.S. developers' prices, he said.

Microsoft's HealthVault allows consumers to store health information online for quick access wherever they're treated, among other functions. Amalga, another Microsoft product, allows organizations to aggregate and mine clinical data.

Epic is developing Care Everywhere, a system to transfer medical records – with patients' consent – across different EHR systems.

It's also working on a Connect the Docs system to facilitate communication and expertise-sharing between physicians, Ms. Faulkner said.

The federal government is working on interoperability fixes, too, said panelists. The current incentives for physicians and hospitals to install EHR systems include the goal that they eventually will be interoperable.

Among other measures, the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act funds the formation of regional health information repositories that can be queried by providers. The Office of the National Coordinator for Health Information Technology created by the act is developing a secure, e-mail–like system over which providers can exchange patients' medical information.

HITECH, however, “is a start, not a finish,” said Rep. Jay Inslee (D-Wash.), also a panelist. He agreed that the challenge remains in “making sure systems can work together.”

Mr. Neupert expressed confidence. “Computing is going to get 1,000 times faster in the next 10 years. With cheap storage and 1,000 times the processing power, we can translate stuff in Epic's data store [and] Cerner's data store and every other data store into a meaningful operational data asset. It's going to be really fabulous for individuals.”