Whitney McKnight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

[email protected]


On Twitter @whitneymcknight

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

[email protected]


On Twitter @whitneymcknight

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

[email protected]


On Twitter @whitneymcknight

TORONTO – The federal mental health parity law, combined with the new focus on value-based payment, will accelerate the revolution in mental health assessment and treatment in the United States and will reduce the financial risk physicians will be exposed to in their practices.

In this interview at the annual meeting of the American Psychiatric Association, former U.S. Rep. Patrick J. Kennedy (D-R.I.) – who, while in Congress, sponsored* the Mental Health Parity and Addiction Equity Act of 2008 – shared his thoughts on how mental health care is about to change.

*Correction, 5/19/2015: An earlier version of this story misstated former Rep. Kennedy's connection to the parity legislation.

[email protected]

On Twitter @whitneymcknight

TORONTO – The federal mental health parity law, combined with the new focus on value-based payment, will accelerate the revolution in mental health assessment and treatment in the United States and will reduce the financial risk physicians will be exposed to in their practices.

In this interview at the annual meeting of the American Psychiatric Association, former U.S. Rep. Patrick J. Kennedy (D-R.I.) – who, while in Congress, sponsored* the Mental Health Parity and Addiction Equity Act of 2008 – shared his thoughts on how mental health care is about to change.

*Correction, 5/19/2015: An earlier version of this story misstated former Rep. Kennedy's connection to the parity legislation.

[email protected]

On Twitter @whitneymcknight

TORONTO – The federal mental health parity law, combined with the new focus on value-based payment, will accelerate the revolution in mental health assessment and treatment in the United States and will reduce the financial risk physicians will be exposed to in their practices.

In this interview at the annual meeting of the American Psychiatric Association, former U.S. Rep. Patrick J. Kennedy (D-R.I.) – who, while in Congress, sponsored* the Mental Health Parity and Addiction Equity Act of 2008 – shared his thoughts on how mental health care is about to change.

*Correction, 5/19/2015: An earlier version of this story misstated former Rep. Kennedy's connection to the parity legislation.

[email protected]

On Twitter @whitneymcknight

BOSTON – When the Medicare Access and CHIP Reauthorization Act goes into effect in 2019, will you be ready?

In a video interview at the annual meeting of the American College of Physicians, Robert B. Doherty, senior vice president of governmental affairs and public policy for the ACP, outlined what physicians need to know about Medicare’s post–Sustainable Growth Rate payment structures, including the difference between MIPS and ACMs.

He also explained how these new Medicare payment structures give physicians more control over their reimbursements while also requiring physicians to endure greater risk.

[email protected]

On Twitter @whitneymcknight

BOSTON – When the Medicare Access and CHIP Reauthorization Act goes into effect in 2019, will you be ready?

In a video interview at the annual meeting of the American College of Physicians, Robert B. Doherty, senior vice president of governmental affairs and public policy for the ACP, outlined what physicians need to know about Medicare’s post–Sustainable Growth Rate payment structures, including the difference between MIPS and ACMs.

He also explained how these new Medicare payment structures give physicians more control over their reimbursements while also requiring physicians to endure greater risk.

[email protected]

On Twitter @whitneymcknight

BOSTON – When the Medicare Access and CHIP Reauthorization Act goes into effect in 2019, will you be ready?

In a video interview at the annual meeting of the American College of Physicians, Robert B. Doherty, senior vice president of governmental affairs and public policy for the ACP, outlined what physicians need to know about Medicare’s post–Sustainable Growth Rate payment structures, including the difference between MIPS and ACMs.

He also explained how these new Medicare payment structures give physicians more control over their reimbursements while also requiring physicians to endure greater risk.

[email protected]

On Twitter @whitneymcknight

BOSTON – New guidelines for cervical cancer screening in average-risk women issued today by the American College of Physicians are intended to standardize care and balance the harms and benefits of testing.

“Historically, physicians have initiated cervical cancer screening too early, and it is performed too frequently,” Dr. Tanveer P. Mir, chair-elect of the ACP’s Board of Regents, said during a media briefing. She noted that physicians also continue to screen patients at low or average risk, such as those who are older or who have had a hysterectomy. “There is much room for improvement.”

Terry Rudd/Frontline Medical News

The ACP defines “average risk” as asymptomatic women with no prior history of precancerous lesions or cervical cancer, women who do not have HIV, and women who were not exposed in utero to certain synthetic estrogens.The potential harms of over testing range from false positives that require painful biopsies to unnecessary hysterectomies.

The American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology have both endorsed the ACP’s new guidelines, which adhere closely to those released by the U.S. Preventive Services Task Force in 2012.

The ACP’s new guidelines advise that women at average risk for cervical cancer who are age 21 or older should undergo cytology testing every 3 years. For women age 30 and older who prefer less frequent screening, physicians should combine HPV (human papillomavirus) testing with the cytology tests every 5 years (Ann. Intern. Med. 2015 April 30 [doi:10.7326/M14-2426]).

Physicians should not screen women aged 65 years and older who have had three consecutive negative cytology results or two consecutive, combined negative cytology and HPV test results within 10 years, with the most recent test having been within 5 years, according to the new guidelines.

The guidelines also recommend that physicians should not screen average-risk women under 21 years of age for cervical cancer. For average-risk women who are 21 or older, cytology testing should not be done more than once every 3 years.

The ACP does not recommend screening in women at average risk who have had a hysterectomy with the removal of their cervix at any age.

“These are guidelines. It really is a clinical decision by the individual physician as to whether they’re going to follow guidelines, and which particular guidelines they’re going to follow,” ACP President David A. Fleming said.

Nearly one-third of all women aged 21-24 years will test positive for HPV, while 12% of women aged 30-34 years and 5% of women aged 60-64 years will also test positive, according to the ACP.

About 13% of all women aged 21-24 years, 7% of those aged 30-34 years, and 3% of women aged 60-64 years will have abnormal cytology. While cytologic abnormalities are common in female patients under 21 years of age, clinically important cervical lesions are not.

The paper’s release is part of the ACP’s effort to prepare its members for the transition from fee-for-service payment models to value-based ones that the U.S. Department of Health & Human Services has said will be the basis for at least 80% of all care by 2018.

“This is high-value care,” Dr. Robert M. Centor, chair of the ACP’s Board of Regents, said of the new guidelines. “Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests and treatments have low value because they do not have enough benefits to justify even their remote costs, and might even be harmful.”

More guidelines will follow as part of the ACP’s campaign to change what Dr. Centor called the “paradigm” of over treatment.

In anticipation of pushback from patients who would prefer to have the screening even if they are at low to average risk, Dr. Fleming said in an interview that the ACP will make educational materials available online for physicians to distribute to patients.

“I try to put it in human terms and explain the unintended consequences of [too much testing], and sometimes I do have a strong recommendation that we either do or do not do whatever the guideline is,” he said. “That’s where the trust relationship comes in.”

[email protected]

On Twitter @whitneymcknight

BOSTON – New guidelines for cervical cancer screening in average-risk women issued today by the American College of Physicians are intended to standardize care and balance the harms and benefits of testing.

“Historically, physicians have initiated cervical cancer screening too early, and it is performed too frequently,” Dr. Tanveer P. Mir, chair-elect of the ACP’s Board of Regents, said during a media briefing. She noted that physicians also continue to screen patients at low or average risk, such as those who are older or who have had a hysterectomy. “There is much room for improvement.”

Terry Rudd/Frontline Medical News

The ACP defines “average risk” as asymptomatic women with no prior history of precancerous lesions or cervical cancer, women who do not have HIV, and women who were not exposed in utero to certain synthetic estrogens.The potential harms of over testing range from false positives that require painful biopsies to unnecessary hysterectomies.

The American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology have both endorsed the ACP’s new guidelines, which adhere closely to those released by the U.S. Preventive Services Task Force in 2012.

The ACP’s new guidelines advise that women at average risk for cervical cancer who are age 21 or older should undergo cytology testing every 3 years. For women age 30 and older who prefer less frequent screening, physicians should combine HPV (human papillomavirus) testing with the cytology tests every 5 years (Ann. Intern. Med. 2015 April 30 [doi:10.7326/M14-2426]).

Physicians should not screen women aged 65 years and older who have had three consecutive negative cytology results or two consecutive, combined negative cytology and HPV test results within 10 years, with the most recent test having been within 5 years, according to the new guidelines.

The guidelines also recommend that physicians should not screen average-risk women under 21 years of age for cervical cancer. For average-risk women who are 21 or older, cytology testing should not be done more than once every 3 years.

The ACP does not recommend screening in women at average risk who have had a hysterectomy with the removal of their cervix at any age.

“These are guidelines. It really is a clinical decision by the individual physician as to whether they’re going to follow guidelines, and which particular guidelines they’re going to follow,” ACP President David A. Fleming said.

Nearly one-third of all women aged 21-24 years will test positive for HPV, while 12% of women aged 30-34 years and 5% of women aged 60-64 years will also test positive, according to the ACP.

About 13% of all women aged 21-24 years, 7% of those aged 30-34 years, and 3% of women aged 60-64 years will have abnormal cytology. While cytologic abnormalities are common in female patients under 21 years of age, clinically important cervical lesions are not.

The paper’s release is part of the ACP’s effort to prepare its members for the transition from fee-for-service payment models to value-based ones that the U.S. Department of Health & Human Services has said will be the basis for at least 80% of all care by 2018.

“This is high-value care,” Dr. Robert M. Centor, chair of the ACP’s Board of Regents, said of the new guidelines. “Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests and treatments have low value because they do not have enough benefits to justify even their remote costs, and might even be harmful.”

More guidelines will follow as part of the ACP’s campaign to change what Dr. Centor called the “paradigm” of over treatment.

In anticipation of pushback from patients who would prefer to have the screening even if they are at low to average risk, Dr. Fleming said in an interview that the ACP will make educational materials available online for physicians to distribute to patients.

“I try to put it in human terms and explain the unintended consequences of [too much testing], and sometimes I do have a strong recommendation that we either do or do not do whatever the guideline is,” he said. “That’s where the trust relationship comes in.”

[email protected]

On Twitter @whitneymcknight

BOSTON – New guidelines for cervical cancer screening in average-risk women issued today by the American College of Physicians are intended to standardize care and balance the harms and benefits of testing.

“Historically, physicians have initiated cervical cancer screening too early, and it is performed too frequently,” Dr. Tanveer P. Mir, chair-elect of the ACP’s Board of Regents, said during a media briefing. She noted that physicians also continue to screen patients at low or average risk, such as those who are older or who have had a hysterectomy. “There is much room for improvement.”

Terry Rudd/Frontline Medical News

The ACP defines “average risk” as asymptomatic women with no prior history of precancerous lesions or cervical cancer, women who do not have HIV, and women who were not exposed in utero to certain synthetic estrogens.The potential harms of over testing range from false positives that require painful biopsies to unnecessary hysterectomies.

The American Congress of Obstetricians and Gynecologists and the American Society for Clinical Pathology have both endorsed the ACP’s new guidelines, which adhere closely to those released by the U.S. Preventive Services Task Force in 2012.

The ACP’s new guidelines advise that women at average risk for cervical cancer who are age 21 or older should undergo cytology testing every 3 years. For women age 30 and older who prefer less frequent screening, physicians should combine HPV (human papillomavirus) testing with the cytology tests every 5 years (Ann. Intern. Med. 2015 April 30 [doi:10.7326/M14-2426]).

Physicians should not screen women aged 65 years and older who have had three consecutive negative cytology results or two consecutive, combined negative cytology and HPV test results within 10 years, with the most recent test having been within 5 years, according to the new guidelines.

The guidelines also recommend that physicians should not screen average-risk women under 21 years of age for cervical cancer. For average-risk women who are 21 or older, cytology testing should not be done more than once every 3 years.

The ACP does not recommend screening in women at average risk who have had a hysterectomy with the removal of their cervix at any age.

“These are guidelines. It really is a clinical decision by the individual physician as to whether they’re going to follow guidelines, and which particular guidelines they’re going to follow,” ACP President David A. Fleming said.

Nearly one-third of all women aged 21-24 years will test positive for HPV, while 12% of women aged 30-34 years and 5% of women aged 60-64 years will also test positive, according to the ACP.

About 13% of all women aged 21-24 years, 7% of those aged 30-34 years, and 3% of women aged 60-64 years will have abnormal cytology. While cytologic abnormalities are common in female patients under 21 years of age, clinically important cervical lesions are not.

The paper’s release is part of the ACP’s effort to prepare its members for the transition from fee-for-service payment models to value-based ones that the U.S. Department of Health & Human Services has said will be the basis for at least 80% of all care by 2018.

“This is high-value care,” Dr. Robert M. Centor, chair of the ACP’s Board of Regents, said of the new guidelines. “Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests and treatments have low value because they do not have enough benefits to justify even their remote costs, and might even be harmful.”

More guidelines will follow as part of the ACP’s campaign to change what Dr. Centor called the “paradigm” of over treatment.

In anticipation of pushback from patients who would prefer to have the screening even if they are at low to average risk, Dr. Fleming said in an interview that the ACP will make educational materials available online for physicians to distribute to patients.

“I try to put it in human terms and explain the unintended consequences of [too much testing], and sometimes I do have a strong recommendation that we either do or do not do whatever the guideline is,” he said. “That’s where the trust relationship comes in.”

[email protected]

On Twitter @whitneymcknight

CHICAGO – Forgetfulness is one of the most common symptoms of adult attention- deficit/hyperactivity disorder and should “definitely” be considered in the differential diagnosis for dementia in older patients who present with this complaint.

That’s the counsel of Dr. Anthony L. Rostain, professor of psychiatry at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia, who spoke at Psychiatry Update 2015, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“An adult with ADHD may have enough resilience that they’ve been functioning well over the decades, but now it affects their ability to hold a job or maintain a relationship,” Dr. Rostain said. “Primary care doctors are typically the first health professional in a position to help these patients identify and manage their condition.”

Learn more about diagnosing and crafting appropriate treatment regimens for adults with ADHD, including helping them to see it as a chronic disorder, not a stigma or disease.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Forgetfulness is one of the most common symptoms of adult attention- deficit/hyperactivity disorder and should “definitely” be considered in the differential diagnosis for dementia in older patients who present with this complaint.

That’s the counsel of Dr. Anthony L. Rostain, professor of psychiatry at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia, who spoke at Psychiatry Update 2015, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“An adult with ADHD may have enough resilience that they’ve been functioning well over the decades, but now it affects their ability to hold a job or maintain a relationship,” Dr. Rostain said. “Primary care doctors are typically the first health professional in a position to help these patients identify and manage their condition.”

Learn more about diagnosing and crafting appropriate treatment regimens for adults with ADHD, including helping them to see it as a chronic disorder, not a stigma or disease.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO – Forgetfulness is one of the most common symptoms of adult attention- deficit/hyperactivity disorder and should “definitely” be considered in the differential diagnosis for dementia in older patients who present with this complaint.

That’s the counsel of Dr. Anthony L. Rostain, professor of psychiatry at the Hospital of the University of Pennsylvania and the Children’s Hospital of Philadelphia, who spoke at Psychiatry Update 2015, sponsored by Current Psychiatry and the American Academy of Clinical Psychiatrists.

“An adult with ADHD may have enough resilience that they’ve been functioning well over the decades, but now it affects their ability to hold a job or maintain a relationship,” Dr. Rostain said. “Primary care doctors are typically the first health professional in a position to help these patients identify and manage their condition.”

Learn more about diagnosing and crafting appropriate treatment regimens for adults with ADHD, including helping them to see it as a chronic disorder, not a stigma or disease.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

WASHINGTON – As the Supreme Court prepares to rule this summer on King v. Burwell, Republican Senators are offering plans should the court strike down subsidies to those who have bought health insurance via the federal exchange.

“I suspect that President Obama will create some kind of executive order to allow states to turn [federally run exchanges] into state exchanges, but the law says you can’t establish a state exchange past a certain date. That throws it back to Congress,” Sen. Ron Johnson (R-Wisc.) said at a press conference.

If there isn’t a way forward already in sight, Sen. Johnson said that he thinks the House Republican leadership will do nothing and tell President Obama, “This is a problem of your own making.”

To avoid that kind of posturing – as well as to convince the Supreme Court that a pro-King ruling would not be harmful to patients – Sen. Johnson said, “We need to have a plan in place.”

His bill, S. 1016, the Preserving Freedom and Choice in Health Care Act, at press time had 31 cosponsors, more than the handful of similar bill introduced in the Senate.

“I’m trying to keep this as simple as possible so it has the greatest chance of success,” Sen. Johnson said. “Let’s maintain the status quo, let’s not throw this whole health insurance market into chaos.”

Should the Supreme Court strike down King v. Burwell, S. 1016 would continue through August 2017 subsidies for patients who currently have insurance bought through a federal exchange – temporarily codifying the status quo and the Obama administration’s interpretation of the Affordable Care Act.

The bill also would repeal both the ACA’s individual mandate to have health insurance and its employer mandate to provide health insurance, as well as the essential health benefits package, which Rep. Johnson said is the reason why the ACA makes health insurance expensive.

“A 60-year-old guy like me has to buy an insurance plan that has maternity coverage. When the government mandates that, it establishes a base price, and it’s going to be higher than if you have an insurance marketplace that doesn’t have all that mandated coverage,” he said. “The way this has all been implemented, if you don’t get the subsidies, you’re paying a lot, and you don’t particularly like Obamacare.”

Time is ticking down for a contingency plan: The Supreme Court is expected to rule the first week of June.

“This may not be the final product,” Sen. Johnson said of his bill, which has yet to be scored by the Congressional Budget Office. “There may be some tweaks and some additions to it over the next week or so, and then whatever comes out of that process is what I think leadership will get behind.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – As the Supreme Court prepares to rule this summer on King v. Burwell, Republican Senators are offering plans should the court strike down subsidies to those who have bought health insurance via the federal exchange.

“I suspect that President Obama will create some kind of executive order to allow states to turn [federally run exchanges] into state exchanges, but the law says you can’t establish a state exchange past a certain date. That throws it back to Congress,” Sen. Ron Johnson (R-Wisc.) said at a press conference.

If there isn’t a way forward already in sight, Sen. Johnson said that he thinks the House Republican leadership will do nothing and tell President Obama, “This is a problem of your own making.”

To avoid that kind of posturing – as well as to convince the Supreme Court that a pro-King ruling would not be harmful to patients – Sen. Johnson said, “We need to have a plan in place.”

His bill, S. 1016, the Preserving Freedom and Choice in Health Care Act, at press time had 31 cosponsors, more than the handful of similar bill introduced in the Senate.

“I’m trying to keep this as simple as possible so it has the greatest chance of success,” Sen. Johnson said. “Let’s maintain the status quo, let’s not throw this whole health insurance market into chaos.”

Should the Supreme Court strike down King v. Burwell, S. 1016 would continue through August 2017 subsidies for patients who currently have insurance bought through a federal exchange – temporarily codifying the status quo and the Obama administration’s interpretation of the Affordable Care Act.

The bill also would repeal both the ACA’s individual mandate to have health insurance and its employer mandate to provide health insurance, as well as the essential health benefits package, which Rep. Johnson said is the reason why the ACA makes health insurance expensive.

“A 60-year-old guy like me has to buy an insurance plan that has maternity coverage. When the government mandates that, it establishes a base price, and it’s going to be higher than if you have an insurance marketplace that doesn’t have all that mandated coverage,” he said. “The way this has all been implemented, if you don’t get the subsidies, you’re paying a lot, and you don’t particularly like Obamacare.”

Time is ticking down for a contingency plan: The Supreme Court is expected to rule the first week of June.

“This may not be the final product,” Sen. Johnson said of his bill, which has yet to be scored by the Congressional Budget Office. “There may be some tweaks and some additions to it over the next week or so, and then whatever comes out of that process is what I think leadership will get behind.”

[email protected]

On Twitter @whitneymcknight

WASHINGTON – As the Supreme Court prepares to rule this summer on King v. Burwell, Republican Senators are offering plans should the court strike down subsidies to those who have bought health insurance via the federal exchange.

“I suspect that President Obama will create some kind of executive order to allow states to turn [federally run exchanges] into state exchanges, but the law says you can’t establish a state exchange past a certain date. That throws it back to Congress,” Sen. Ron Johnson (R-Wisc.) said at a press conference.

If there isn’t a way forward already in sight, Sen. Johnson said that he thinks the House Republican leadership will do nothing and tell President Obama, “This is a problem of your own making.”

To avoid that kind of posturing – as well as to convince the Supreme Court that a pro-King ruling would not be harmful to patients – Sen. Johnson said, “We need to have a plan in place.”

His bill, S. 1016, the Preserving Freedom and Choice in Health Care Act, at press time had 31 cosponsors, more than the handful of similar bill introduced in the Senate.

“I’m trying to keep this as simple as possible so it has the greatest chance of success,” Sen. Johnson said. “Let’s maintain the status quo, let’s not throw this whole health insurance market into chaos.”

Should the Supreme Court strike down King v. Burwell, S. 1016 would continue through August 2017 subsidies for patients who currently have insurance bought through a federal exchange – temporarily codifying the status quo and the Obama administration’s interpretation of the Affordable Care Act.

The bill also would repeal both the ACA’s individual mandate to have health insurance and its employer mandate to provide health insurance, as well as the essential health benefits package, which Rep. Johnson said is the reason why the ACA makes health insurance expensive.

“A 60-year-old guy like me has to buy an insurance plan that has maternity coverage. When the government mandates that, it establishes a base price, and it’s going to be higher than if you have an insurance marketplace that doesn’t have all that mandated coverage,” he said. “The way this has all been implemented, if you don’t get the subsidies, you’re paying a lot, and you don’t particularly like Obamacare.”

Time is ticking down for a contingency plan: The Supreme Court is expected to rule the first week of June.

“This may not be the final product,” Sen. Johnson said of his bill, which has yet to be scored by the Congressional Budget Office. “There may be some tweaks and some additions to it over the next week or so, and then whatever comes out of that process is what I think leadership will get behind.”

[email protected]

On Twitter @whitneymcknight

COLORADO SPRINGS – Results from a large, diverse community cohort study of genotyped youth could lead the way to early identification of those most likely to develop psychosis.

Data from the Philadelphia Neurodevelopmental Cohort study are now being analyzed in hopes that patterns emerging from an assessment of 9,421 Philadelphia-area children and young people aged 8-21 years will help researchers identify biomarkers that can be used to identify trajectories of mental illness before the point of clinical diagnosis.

Whitney McKnight/Frontline Medical News

The hope is that this will lead to the creation of a psychosis screening tool, Dr. Raquel E. Gur, one of the lead authors of the study and the Karl and Linda Rickels Professor of Psychiatry at the University of Pennsylvania, Philadelphia, said in an interview at the International Congress on Schizophrenia Research.

Speaking about the difficulties of telling a family that their child is at risk for psychosis, she added: “It’s complex. The parents are often terrified, but it’s a reality. So what can we do to intervene early?” Earlier intervention can lead to better outcomes, she said.

Study participants were recruited from nearly 14,000 previously identified and genotyped children with varying levels of health and a range of medical conditions who were seen at pediatric facilities in Philadelphia and the surrounding region. The mean age of those studied was 14.2 years; 56% were white. Black children and young people represented a third of all study participants, and girls comprised slightly more than half.

In addition to current medical histories, Dr. Gur and her colleagues collected information on participants’ psychiatric and psychological histories using a comprehensive computerized tool to evaluate psychopathology domains such as mood and anxiety disorders. From this, they developed an identification matrix consisting of a strong general psychopathology factor and specific anxious-misery, fear, and behavior factors. They also developed a psychosis spectrum, embedded into the psychopathology screen, that included a general factor and three specific factors: ideas about special abilities/persecution, unusual thoughts/perceptions, and negative/disorganized symptoms. Positive threshold psychotic symptoms such as hallucinations and delusions were assessed with negative/disorganized symptoms typical of the prodromal phase of psychosis.

Dr. Gur said that, because of the absence of data on psychosis in preadolescence, one of their aims was to determine the prevalence of psychotic symptoms – similar to the prodromal symptoms typically displayed in adolescents – in the nearly 5,000 8- to 11-year-olds in the study. The results, she said, were that 3.7% reported psychotic symptoms, while an additional 12.3% reported significant positive subthreshold symptoms such as auditory disturbances and reality confusion. Of those who reported such symptoms, 2.3% reported being distressed by their negative symptoms, in part because they interfered with normal levels of functioning.

“Notably, the young participants were reporting much more than the parents were reporting,” Dr. Gur said. “This pattern shows you need to assess the children directly.”

Severe subthreshold symptoms such as delusions, hallucinations, and auditory disturbances occurred at a level Dr. Gur said was consistent in studies of help-seeking individuals, although more than a third of the study participants had never discussed their distress with anyone.

“Nobody knew what these kids were going through,” she said. “We were the first mental health professionals to know. Not a school nurse, not clergy, nobody. This is a big burden for a young person.”

Even so, she said, these prodromal signs were not appearing in a vacuum. “What we commonly saw was depression, anxiety, difficulty with impulse control, substance use, and suicidal ideation. This is an important clinical period.”

Additional predictive factors for having symptoms of psychosis that Dr. Gur listed included being male and of European descent, cannabis use, reduced global functioning, and being distressed.

Being female had a high association with the anxious-misery factor and low association with the behavior factors.

The assessment’s behavior factor correlated negatively (0.21) with the overall accuracy of neurocognitive performance, particularly in executive and complex reasoning.

If it were possible to determine a child’s chronological age according to a composite score from his neurocognitive performance on the assessment, Dr. Gur said, this might mean it would be possible to determine who would benefit from intervention. Because the study looked for global psychopathologies, Dr. Gur theorized, “maybe all psychopathology is associated with cognitive performance and chronological age. It appears that having a subthreshold psychotic symptom infers vulnerability, so the expectation that somebody who is on the psychotic spectrum at age 16 would perform cognitively like a typically developing teen will not be met. This is something that can be tracked both individually and as a group. It is good clinical data that can be used to appraise child development, like height and weight.”

In the subset of study participants who underwent functional MRI, activation of working memory in the regions of the brain associated with executive function in those positively identified on the psychosis spectrum was lower than in those scored as developing normally (P < .05). Deficits in prefrontal cognitive activity also were noted in the group on the psychosis spectrum when compared with those not on the spectrum (P < .001), although no correlation was found with positive symptom severity. Also in the psychosis-spectrum group, there was elevated activity in the amygdala and other brain regions typically associated with fear, in response to being shown threatening facial expressions (P < .05). The response in the amygdala correlated with positive symptom severity (P = .01) but not with cognitive deficits.

Dr. Gur did not have any relevant disclosures.

[email protected]

On Twitter @whitneymcknight

COLORADO SPRINGS – Results from a large, diverse community cohort study of genotyped youth could lead the way to early identification of those most likely to develop psychosis.

Data from the Philadelphia Neurodevelopmental Cohort study are now being analyzed in hopes that patterns emerging from an assessment of 9,421 Philadelphia-area children and young people aged 8-21 years will help researchers identify biomarkers that can be used to identify trajectories of mental illness before the point of clinical diagnosis.

Whitney McKnight/Frontline Medical News

The hope is that this will lead to the creation of a psychosis screening tool, Dr. Raquel E. Gur, one of the lead authors of the study and the Karl and Linda Rickels Professor of Psychiatry at the University of Pennsylvania, Philadelphia, said in an interview at the International Congress on Schizophrenia Research.

Speaking about the difficulties of telling a family that their child is at risk for psychosis, she added: “It’s complex. The parents are often terrified, but it’s a reality. So what can we do to intervene early?” Earlier intervention can lead to better outcomes, she said.

Study participants were recruited from nearly 14,000 previously identified and genotyped children with varying levels of health and a range of medical conditions who were seen at pediatric facilities in Philadelphia and the surrounding region. The mean age of those studied was 14.2 years; 56% were white. Black children and young people represented a third of all study participants, and girls comprised slightly more than half.

In addition to current medical histories, Dr. Gur and her colleagues collected information on participants’ psychiatric and psychological histories using a comprehensive computerized tool to evaluate psychopathology domains such as mood and anxiety disorders. From this, they developed an identification matrix consisting of a strong general psychopathology factor and specific anxious-misery, fear, and behavior factors. They also developed a psychosis spectrum, embedded into the psychopathology screen, that included a general factor and three specific factors: ideas about special abilities/persecution, unusual thoughts/perceptions, and negative/disorganized symptoms. Positive threshold psychotic symptoms such as hallucinations and delusions were assessed with negative/disorganized symptoms typical of the prodromal phase of psychosis.

Dr. Gur said that, because of the absence of data on psychosis in preadolescence, one of their aims was to determine the prevalence of psychotic symptoms – similar to the prodromal symptoms typically displayed in adolescents – in the nearly 5,000 8- to 11-year-olds in the study. The results, she said, were that 3.7% reported psychotic symptoms, while an additional 12.3% reported significant positive subthreshold symptoms such as auditory disturbances and reality confusion. Of those who reported such symptoms, 2.3% reported being distressed by their negative symptoms, in part because they interfered with normal levels of functioning.

“Notably, the young participants were reporting much more than the parents were reporting,” Dr. Gur said. “This pattern shows you need to assess the children directly.”

Severe subthreshold symptoms such as delusions, hallucinations, and auditory disturbances occurred at a level Dr. Gur said was consistent in studies of help-seeking individuals, although more than a third of the study participants had never discussed their distress with anyone.

“Nobody knew what these kids were going through,” she said. “We were the first mental health professionals to know. Not a school nurse, not clergy, nobody. This is a big burden for a young person.”

Even so, she said, these prodromal signs were not appearing in a vacuum. “What we commonly saw was depression, anxiety, difficulty with impulse control, substance use, and suicidal ideation. This is an important clinical period.”

Additional predictive factors for having symptoms of psychosis that Dr. Gur listed included being male and of European descent, cannabis use, reduced global functioning, and being distressed.

Being female had a high association with the anxious-misery factor and low association with the behavior factors.

The assessment’s behavior factor correlated negatively (0.21) with the overall accuracy of neurocognitive performance, particularly in executive and complex reasoning.

If it were possible to determine a child’s chronological age according to a composite score from his neurocognitive performance on the assessment, Dr. Gur said, this might mean it would be possible to determine who would benefit from intervention. Because the study looked for global psychopathologies, Dr. Gur theorized, “maybe all psychopathology is associated with cognitive performance and chronological age. It appears that having a subthreshold psychotic symptom infers vulnerability, so the expectation that somebody who is on the psychotic spectrum at age 16 would perform cognitively like a typically developing teen will not be met. This is something that can be tracked both individually and as a group. It is good clinical data that can be used to appraise child development, like height and weight.”

In the subset of study participants who underwent functional MRI, activation of working memory in the regions of the brain associated with executive function in those positively identified on the psychosis spectrum was lower than in those scored as developing normally (P < .05). Deficits in prefrontal cognitive activity also were noted in the group on the psychosis spectrum when compared with those not on the spectrum (P < .001), although no correlation was found with positive symptom severity. Also in the psychosis-spectrum group, there was elevated activity in the amygdala and other brain regions typically associated with fear, in response to being shown threatening facial expressions (P < .05). The response in the amygdala correlated with positive symptom severity (P = .01) but not with cognitive deficits.

Dr. Gur did not have any relevant disclosures.

[email protected]

On Twitter @whitneymcknight

COLORADO SPRINGS – Results from a large, diverse community cohort study of genotyped youth could lead the way to early identification of those most likely to develop psychosis.

Data from the Philadelphia Neurodevelopmental Cohort study are now being analyzed in hopes that patterns emerging from an assessment of 9,421 Philadelphia-area children and young people aged 8-21 years will help researchers identify biomarkers that can be used to identify trajectories of mental illness before the point of clinical diagnosis.

Whitney McKnight/Frontline Medical News

The hope is that this will lead to the creation of a psychosis screening tool, Dr. Raquel E. Gur, one of the lead authors of the study and the Karl and Linda Rickels Professor of Psychiatry at the University of Pennsylvania, Philadelphia, said in an interview at the International Congress on Schizophrenia Research.

Speaking about the difficulties of telling a family that their child is at risk for psychosis, she added: “It’s complex. The parents are often terrified, but it’s a reality. So what can we do to intervene early?” Earlier intervention can lead to better outcomes, she said.

Study participants were recruited from nearly 14,000 previously identified and genotyped children with varying levels of health and a range of medical conditions who were seen at pediatric facilities in Philadelphia and the surrounding region. The mean age of those studied was 14.2 years; 56% were white. Black children and young people represented a third of all study participants, and girls comprised slightly more than half.

In addition to current medical histories, Dr. Gur and her colleagues collected information on participants’ psychiatric and psychological histories using a comprehensive computerized tool to evaluate psychopathology domains such as mood and anxiety disorders. From this, they developed an identification matrix consisting of a strong general psychopathology factor and specific anxious-misery, fear, and behavior factors. They also developed a psychosis spectrum, embedded into the psychopathology screen, that included a general factor and three specific factors: ideas about special abilities/persecution, unusual thoughts/perceptions, and negative/disorganized symptoms. Positive threshold psychotic symptoms such as hallucinations and delusions were assessed with negative/disorganized symptoms typical of the prodromal phase of psychosis.

Dr. Gur said that, because of the absence of data on psychosis in preadolescence, one of their aims was to determine the prevalence of psychotic symptoms – similar to the prodromal symptoms typically displayed in adolescents – in the nearly 5,000 8- to 11-year-olds in the study. The results, she said, were that 3.7% reported psychotic symptoms, while an additional 12.3% reported significant positive subthreshold symptoms such as auditory disturbances and reality confusion. Of those who reported such symptoms, 2.3% reported being distressed by their negative symptoms, in part because they interfered with normal levels of functioning.

“Notably, the young participants were reporting much more than the parents were reporting,” Dr. Gur said. “This pattern shows you need to assess the children directly.”

Severe subthreshold symptoms such as delusions, hallucinations, and auditory disturbances occurred at a level Dr. Gur said was consistent in studies of help-seeking individuals, although more than a third of the study participants had never discussed their distress with anyone.

“Nobody knew what these kids were going through,” she said. “We were the first mental health professionals to know. Not a school nurse, not clergy, nobody. This is a big burden for a young person.”

Even so, she said, these prodromal signs were not appearing in a vacuum. “What we commonly saw was depression, anxiety, difficulty with impulse control, substance use, and suicidal ideation. This is an important clinical period.”

Additional predictive factors for having symptoms of psychosis that Dr. Gur listed included being male and of European descent, cannabis use, reduced global functioning, and being distressed.

Being female had a high association with the anxious-misery factor and low association with the behavior factors.

The assessment’s behavior factor correlated negatively (0.21) with the overall accuracy of neurocognitive performance, particularly in executive and complex reasoning.

If it were possible to determine a child’s chronological age according to a composite score from his neurocognitive performance on the assessment, Dr. Gur said, this might mean it would be possible to determine who would benefit from intervention. Because the study looked for global psychopathologies, Dr. Gur theorized, “maybe all psychopathology is associated with cognitive performance and chronological age. It appears that having a subthreshold psychotic symptom infers vulnerability, so the expectation that somebody who is on the psychotic spectrum at age 16 would perform cognitively like a typically developing teen will not be met. This is something that can be tracked both individually and as a group. It is good clinical data that can be used to appraise child development, like height and weight.”

In the subset of study participants who underwent functional MRI, activation of working memory in the regions of the brain associated with executive function in those positively identified on the psychosis spectrum was lower than in those scored as developing normally (P < .05). Deficits in prefrontal cognitive activity also were noted in the group on the psychosis spectrum when compared with those not on the spectrum (P < .001), although no correlation was found with positive symptom severity. Also in the psychosis-spectrum group, there was elevated activity in the amygdala and other brain regions typically associated with fear, in response to being shown threatening facial expressions (P < .05). The response in the amygdala correlated with positive symptom severity (P = .01) but not with cognitive deficits.

Dr. Gur did not have any relevant disclosures.

[email protected]

On Twitter @whitneymcknight

CHICAGO– Helping patients quit smoking, whether those with severe mental illness or comorbid depression, is an “excellent opportunity” for primary care doctors and psychiatrists to work together.

That’s according to Dr. Robert M. Anthenelli, a professor of psychiatry at the University of California, San Diego, and director of the Pacific Treatment and Research Center there.

Depression and smoking are often comorbid in patients, and nearly half of all tobacco products consumed in the United States are done so by people with some form of a psychiatric or other substance use disorder. In this interview, recorded at the meeting, sponsored by Current Psychiatry and American Academy of Clinical Psychiatrists, Dr. Anthenelli discusses brain changes in tobacco use, why there is a link between smoking and mental illness, and what primary care physicians can do to help their patients who smoke. He also addresses whether complete cessation is essential to one’s well-being.

Dr. Anthenelli is a consultant to Pfizer and Arena Pharmaceuticals.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO– Helping patients quit smoking, whether those with severe mental illness or comorbid depression, is an “excellent opportunity” for primary care doctors and psychiatrists to work together.

That’s according to Dr. Robert M. Anthenelli, a professor of psychiatry at the University of California, San Diego, and director of the Pacific Treatment and Research Center there.

Depression and smoking are often comorbid in patients, and nearly half of all tobacco products consumed in the United States are done so by people with some form of a psychiatric or other substance use disorder. In this interview, recorded at the meeting, sponsored by Current Psychiatry and American Academy of Clinical Psychiatrists, Dr. Anthenelli discusses brain changes in tobacco use, why there is a link between smoking and mental illness, and what primary care physicians can do to help their patients who smoke. He also addresses whether complete cessation is essential to one’s well-being.

Dr. Anthenelli is a consultant to Pfizer and Arena Pharmaceuticals.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight

CHICAGO– Helping patients quit smoking, whether those with severe mental illness or comorbid depression, is an “excellent opportunity” for primary care doctors and psychiatrists to work together.

That’s according to Dr. Robert M. Anthenelli, a professor of psychiatry at the University of California, San Diego, and director of the Pacific Treatment and Research Center there.

Depression and smoking are often comorbid in patients, and nearly half of all tobacco products consumed in the United States are done so by people with some form of a psychiatric or other substance use disorder. In this interview, recorded at the meeting, sponsored by Current Psychiatry and American Academy of Clinical Psychiatrists, Dr. Anthenelli discusses brain changes in tobacco use, why there is a link between smoking and mental illness, and what primary care physicians can do to help their patients who smoke. He also addresses whether complete cessation is essential to one’s well-being.

Dr. Anthenelli is a consultant to Pfizer and Arena Pharmaceuticals.

Current Psychiatry and this news organization are owned by the same parent company.

[email protected]

On Twitter @whitneymcknight