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Structural racism tied to psychosis risk in Black people
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Social and economic disparities are linked to an increased risk for psychosis in Black and Latino communities, new research shows.
Results of a literature review of social and economic disparities in mental illness suggest that “structural racism” contributes to social and environmental conditions that affect psychosis risk.
“Black and Latino people suffer disproportionately from psychosis risk factors, at the neighborhood level and at the individual level, in large part as a result of structural racism,” study investigator Deidre M. Anglin, PhD, associate professor, department of psychology, City College of New York (N.Y.), told reporters attending a press briefing.
The social environment, which, for minorities, involves disadvantage and discrimination, may account for this increased psychosis risk, perhaps even more so than genetics, she said. Structural racism “is a critical public health threat,” Dr. Anglin added.
The findings were presented at the virtual American Psychiatric Association annual meeting and were simultaneously published online May 3 in The American Journal of Psychiatry.
Perpetual disadvantage
Dr. Anglin and colleagues examined U.S.-based evidence connecting characteristics of social environments with outcomes across the psychosis continuum – from psychotic experiences to schizophrenia.
Citing numerous studies, the researchers highlighted three key areas that reflect social and environmental conditions that may affect psychosis risk, and that disproportionately affect minorities. These were neighborhood factors, trauma in a U.S. context, and racial disparities during the prenatal and perinatal periods.
The data that were related to neighborhoods revealed “just how much racism has historically structured U.S. neighborhoods in ways that generationally perpetuate disadvantage for racially minoritized communities,” said Dr. Anglin.
“This happens through inequitable access to resources, such as health care, clean air, education, [and] employment, but also in terms of disproportionate exposure to environmental toxins and stressors,” she said.
These neighborhood factors are associated with cumulative stress that may be linked to heightened risk for psychosis, the investigators noted.
U.S. studies show that rates of adverse childhood experiences, such as abuse and emotional and physical neglect, are higher among racial and ethnic minorities.
Police victimization and gun violence disproportionately affect racial minorities and create what the investigators call “a unique type of collective trauma” in the United States. They note that Black men have a 1 in 1,000 chance of being victims of lethal force by police over their lifetimes. By comparison, White men have a 39 in 100,000 chance.
One study of a diverse sample from four large U.S. urban centers showed that those who self-reported different types of police victimization were more likely to report psychotic experiences. Another study showed that greater exposure to gun violence fatalities, regardless of police involvement, was positively associated with psychotic experiences.
Obstetric complications
A variety of obstetric complications, including infection, maternal inflammation, and stress, have been associated with increased risk for psychotic disorders in U.S. samples.
“What we saw emerge from the literature is that Black women in the U.S. are at substantially increased risk for many of these obstetrical complications compared to White women, and this is not necessarily explained by socioeconomic status,” said Dr. Anglin.
Neighborhood- and individual-level factors appear to affect the disparity in these outcomes. A recent study revealed that exposure to environmental contaminants such as air pollution is associated with higher rates of preterm birth and low birth weight differentially in Black mothers compared with other mothers, “possibly as a result of an interaction between prenatal stress and contaminants,” the investigators noted.
Research also indicates that Black women are more likely to have lower levels of cortisol during the second trimester of pregnancy compared with women of other racial and ethnic groups. Cortisol is essential for fetal growth. Evidence links lower cortisol levels in later stages of pregnancy with decreased fetal growth in individuals who develop schizophrenia.
, compared with White women of the same socioeconomic status.
Such findings “highlight a complex picture” involving maternal cortisol levels and other stress biomarkers, “potentially leading to poor birth outcomes and subsequent risk for psychotic disorders in adulthood,” the investigators noted.
The researchers call for the dismantling of structural racism and the social policies and norms it shapes. They also recommend changes in health care policy and in the approach to early intervention for psychosis among Black and other racially-minoritized groups.
“Altogether, the current evidence suggests the need to identify, address, and tackle the social determinants deeply ingrained in U.S. society, in tandem with empowering the most marginalized communities,” the researchers wrote.
“We recommend that the field of psychiatry devote considerably more effort to addressing structural racism and social determinants of psychosis in funding priorities, training, and intervention development,” they added.
Dr. Anglin suggests that mental health providers use what she called a “cultural formulation interview” that takes a person’s environmental and social context into consideration. Studies show that incorporating this into clinical practice helps reduce misdiagnosis of mental illness in Black populations, she said.
Call to action
Commenting on the findings in an interview, Ned H. Kalin, MD, editor of The American Journal of Psychiatry and professor and chair of the department of psychiatry, University of Wisconsin, Madison, said the study was well done and serves as a “call to action” to address the impact of structural racism on mental health issues and psychiatric diseases.
The article highlights the need for “collecting better data” on structural racism, said Dr. Kalin. “We know it’s a big issue, but we can’t even quantitate it, so we need some fundamental measures to use as a benchmark as we move forward, as we try to make change.”
He noted that racism “is so embedded in one’s experience and in our society that we sort of don’t even think about it as a trauma.”
In psychiatry, for example, trauma is often thought of as a loss or a traumatic event. “We don’t typically think of trauma as an experience that pervades one’s entire life,” but that needs to change, he said. “At the individual level and in the doctor’s office, being sensitive to and aware of these issues is absolutely critical.”
Dr. Anglin and Dr. Kalin have disclosed no relevant financial relationships.
A version of this article first appeared on Medscape.com.
Reframing AUD as treatable may reduce stigma
As alcohol-related death and disease rates rise, framing alcohol use disorder as a treatable disease with neurobiologic underpinnings might help reduce the stigma that many patients endure, according to George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
“Alcohol misuse and alcohol use disorder (AUD) have not gone away during the opioid crisis, and [they have] not gone away during the current (COVID-19) pandemic,” Dr. Koob said in a presentation at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
There are at least 14 million individuals in the United States with AUD now, compared with 2 million with opioid use disorder, Dr. Koob said.
– just like hypertension or diabetes are treatable chronic conditions.
However, framing AUD as a treatable chronic condition is just one of many issues that need to be addressed, he said, adding that rates of screening and referral for AUD need to be increased among patients with other mental health conditions.
Psychiatrists can play a key role in reducing that screening and treatment gap, though concerningly, data suggest fewer than half of psychiatric patients with substance use disorders (SUDs) are being diagnosed or treated, said Andrew J. Saxon, MD, director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System in Seattle.
Only about 9% of psychiatrist office visits from 2012 to 2015 involved a substance use disorder diagnosis or prescribed medication, whereas at least 20% of adults with mental health conditions also have an SUD, according to authors of a recent study in Psychiatric Services (2018 Jan 16. doi: 10.1176/appi.ps.201700457).
Better efforts are needed to improve training or somehow better incentivize psychiatrists to screen for alcohol use disorder and make sure patients get treatment for addiction, Dr. Saxon said in an interview.
“What we have is a lack of subspecialists in addiction psychiatry,” said Dr. Saxon, former director of the addiction psychiatry residency program at the University of Washington. “That becomes self-perpetuating, because we don’t have the knowledge experts to train the residents, and therefore, the residency programs don’t provide a rich enough experience.”
Changes in alcohol-related deaths
A new report (Alcoholism Clin Exper Res. 2020 Jan;44[1]:178-87) highlights the gravity of the AUD problem, showing that alcohol-related deaths have doubled over the past few decades, Dr. Koob said in his presentation.
Among individuals 16 years of age or older, the number of alcohol-related deaths in the United States rose from 35,914 in 1999 to 72,558 (or about 2.6% of all U.S. deaths) in 2017, according to that report, which was based on U.S. mortality data from the National Center for Health Statistics. The largest increase was seen in non-Hispanic white females, according to the investigators.
Alcohol is playing a more prominent role in “deaths of despair,” said Dr. Koob, noting that it contributes to about one-quarter of suicides and up to 20% of drug overdoses. “Probably even more salient is that half of liver disease in the United States is now caused by alcohol,” he added.
Misuse of alcohol is correlated with poor mental health, an observation that Dr. Koob said was particularly relevant to the current COVID-19 pandemic, he said, since alcohol is commonly used to cope with stress and symptoms of mental health conditions.
“In the end, it makes the prognosis worse,” he said.
Addressing AUD stigma
A better understanding of the neurobiology of addiction may reduce the stigma associated with AUD, helping reframe the issue as a “health condition, rather than as a moral failing,” Dr. Koob said.
Stigma remains a major barrier to AUD treatment, he added, explaining that factors contributing to stigma include shame patients may feel for what they perceive as a personal failure, and lack of knowledge about treatment options.
Separating AUD treatment from primary care exacerbates that problem, perpetuating the sense that AUD is somehow a “different” kind of issue, he said.
Health care clinicians in primary care can help alleviate the stigma by engaging in screening and offering referral to treatment, he said, adding that the NIAAA offers a navigator website designed to help individuals negotiate the process of choosing a treatment approach for AUD.
Language matters, according to Dr. Koob, who suggested using nonstigmatizing “person-first” terminology to refer to affected individuals not as alcoholics, but as “persons with AUD.”
Challenges ahead for AUD
There’s still a lot of work to be done to understand differences in alcohol pathology between men and women, especially as gaps narrow between the sexes for AUD incidence, early-onset drinking, frequency and intensity of drinking, and self-reported consequences, Dr. Koob said.
Age differences are also important to study. On one hand, older individuals appear to be more sensitive to the effects of alcohol, he said, because of metabolism changes, neurocognitive decline, and “inflamm-aging,” or the chronic and low level inflammatory state associated with aging.
Adolescents are also an increased-risk population of research interest, since brain wiring connections are “particularly sensitive” to alcohol in the teen years, potentially setting up changes in vulnerability to AUD that last into adulthood.
Other challenges include the unmet need for better and more individualized AUD treatments, the issue of alcohol tolerance, which Dr. Koob said has been “ignored for many years” by researchers, the contribution of pain to AUD, and the way that dysregulated sleep contributes to AUD, and vice versa.
Research likewise remains “challenging” regarding conditions that are frequently found in conjunction with AUD, such as major depressive episodes, anxiety disorders, and posttraumatic stress disorder: “These are all areas that we’re intensely interested in as comorbidities with AUD,” Dr. Koob said.
Dr. Koob reported no disclosures.
SOURCE: Koob GF. APA 2020, Abstract.
As alcohol-related death and disease rates rise, framing alcohol use disorder as a treatable disease with neurobiologic underpinnings might help reduce the stigma that many patients endure, according to George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
“Alcohol misuse and alcohol use disorder (AUD) have not gone away during the opioid crisis, and [they have] not gone away during the current (COVID-19) pandemic,” Dr. Koob said in a presentation at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
There are at least 14 million individuals in the United States with AUD now, compared with 2 million with opioid use disorder, Dr. Koob said.
– just like hypertension or diabetes are treatable chronic conditions.
However, framing AUD as a treatable chronic condition is just one of many issues that need to be addressed, he said, adding that rates of screening and referral for AUD need to be increased among patients with other mental health conditions.
Psychiatrists can play a key role in reducing that screening and treatment gap, though concerningly, data suggest fewer than half of psychiatric patients with substance use disorders (SUDs) are being diagnosed or treated, said Andrew J. Saxon, MD, director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System in Seattle.
Only about 9% of psychiatrist office visits from 2012 to 2015 involved a substance use disorder diagnosis or prescribed medication, whereas at least 20% of adults with mental health conditions also have an SUD, according to authors of a recent study in Psychiatric Services (2018 Jan 16. doi: 10.1176/appi.ps.201700457).
Better efforts are needed to improve training or somehow better incentivize psychiatrists to screen for alcohol use disorder and make sure patients get treatment for addiction, Dr. Saxon said in an interview.
“What we have is a lack of subspecialists in addiction psychiatry,” said Dr. Saxon, former director of the addiction psychiatry residency program at the University of Washington. “That becomes self-perpetuating, because we don’t have the knowledge experts to train the residents, and therefore, the residency programs don’t provide a rich enough experience.”
Changes in alcohol-related deaths
A new report (Alcoholism Clin Exper Res. 2020 Jan;44[1]:178-87) highlights the gravity of the AUD problem, showing that alcohol-related deaths have doubled over the past few decades, Dr. Koob said in his presentation.
Among individuals 16 years of age or older, the number of alcohol-related deaths in the United States rose from 35,914 in 1999 to 72,558 (or about 2.6% of all U.S. deaths) in 2017, according to that report, which was based on U.S. mortality data from the National Center for Health Statistics. The largest increase was seen in non-Hispanic white females, according to the investigators.
Alcohol is playing a more prominent role in “deaths of despair,” said Dr. Koob, noting that it contributes to about one-quarter of suicides and up to 20% of drug overdoses. “Probably even more salient is that half of liver disease in the United States is now caused by alcohol,” he added.
Misuse of alcohol is correlated with poor mental health, an observation that Dr. Koob said was particularly relevant to the current COVID-19 pandemic, he said, since alcohol is commonly used to cope with stress and symptoms of mental health conditions.
“In the end, it makes the prognosis worse,” he said.
Addressing AUD stigma
A better understanding of the neurobiology of addiction may reduce the stigma associated with AUD, helping reframe the issue as a “health condition, rather than as a moral failing,” Dr. Koob said.
Stigma remains a major barrier to AUD treatment, he added, explaining that factors contributing to stigma include shame patients may feel for what they perceive as a personal failure, and lack of knowledge about treatment options.
Separating AUD treatment from primary care exacerbates that problem, perpetuating the sense that AUD is somehow a “different” kind of issue, he said.
Health care clinicians in primary care can help alleviate the stigma by engaging in screening and offering referral to treatment, he said, adding that the NIAAA offers a navigator website designed to help individuals negotiate the process of choosing a treatment approach for AUD.
Language matters, according to Dr. Koob, who suggested using nonstigmatizing “person-first” terminology to refer to affected individuals not as alcoholics, but as “persons with AUD.”
Challenges ahead for AUD
There’s still a lot of work to be done to understand differences in alcohol pathology between men and women, especially as gaps narrow between the sexes for AUD incidence, early-onset drinking, frequency and intensity of drinking, and self-reported consequences, Dr. Koob said.
Age differences are also important to study. On one hand, older individuals appear to be more sensitive to the effects of alcohol, he said, because of metabolism changes, neurocognitive decline, and “inflamm-aging,” or the chronic and low level inflammatory state associated with aging.
Adolescents are also an increased-risk population of research interest, since brain wiring connections are “particularly sensitive” to alcohol in the teen years, potentially setting up changes in vulnerability to AUD that last into adulthood.
Other challenges include the unmet need for better and more individualized AUD treatments, the issue of alcohol tolerance, which Dr. Koob said has been “ignored for many years” by researchers, the contribution of pain to AUD, and the way that dysregulated sleep contributes to AUD, and vice versa.
Research likewise remains “challenging” regarding conditions that are frequently found in conjunction with AUD, such as major depressive episodes, anxiety disorders, and posttraumatic stress disorder: “These are all areas that we’re intensely interested in as comorbidities with AUD,” Dr. Koob said.
Dr. Koob reported no disclosures.
SOURCE: Koob GF. APA 2020, Abstract.
As alcohol-related death and disease rates rise, framing alcohol use disorder as a treatable disease with neurobiologic underpinnings might help reduce the stigma that many patients endure, according to George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
“Alcohol misuse and alcohol use disorder (AUD) have not gone away during the opioid crisis, and [they have] not gone away during the current (COVID-19) pandemic,” Dr. Koob said in a presentation at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
There are at least 14 million individuals in the United States with AUD now, compared with 2 million with opioid use disorder, Dr. Koob said.
– just like hypertension or diabetes are treatable chronic conditions.
However, framing AUD as a treatable chronic condition is just one of many issues that need to be addressed, he said, adding that rates of screening and referral for AUD need to be increased among patients with other mental health conditions.
Psychiatrists can play a key role in reducing that screening and treatment gap, though concerningly, data suggest fewer than half of psychiatric patients with substance use disorders (SUDs) are being diagnosed or treated, said Andrew J. Saxon, MD, director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System in Seattle.
Only about 9% of psychiatrist office visits from 2012 to 2015 involved a substance use disorder diagnosis or prescribed medication, whereas at least 20% of adults with mental health conditions also have an SUD, according to authors of a recent study in Psychiatric Services (2018 Jan 16. doi: 10.1176/appi.ps.201700457).
Better efforts are needed to improve training or somehow better incentivize psychiatrists to screen for alcohol use disorder and make sure patients get treatment for addiction, Dr. Saxon said in an interview.
“What we have is a lack of subspecialists in addiction psychiatry,” said Dr. Saxon, former director of the addiction psychiatry residency program at the University of Washington. “That becomes self-perpetuating, because we don’t have the knowledge experts to train the residents, and therefore, the residency programs don’t provide a rich enough experience.”
Changes in alcohol-related deaths
A new report (Alcoholism Clin Exper Res. 2020 Jan;44[1]:178-87) highlights the gravity of the AUD problem, showing that alcohol-related deaths have doubled over the past few decades, Dr. Koob said in his presentation.
Among individuals 16 years of age or older, the number of alcohol-related deaths in the United States rose from 35,914 in 1999 to 72,558 (or about 2.6% of all U.S. deaths) in 2017, according to that report, which was based on U.S. mortality data from the National Center for Health Statistics. The largest increase was seen in non-Hispanic white females, according to the investigators.
Alcohol is playing a more prominent role in “deaths of despair,” said Dr. Koob, noting that it contributes to about one-quarter of suicides and up to 20% of drug overdoses. “Probably even more salient is that half of liver disease in the United States is now caused by alcohol,” he added.
Misuse of alcohol is correlated with poor mental health, an observation that Dr. Koob said was particularly relevant to the current COVID-19 pandemic, he said, since alcohol is commonly used to cope with stress and symptoms of mental health conditions.
“In the end, it makes the prognosis worse,” he said.
Addressing AUD stigma
A better understanding of the neurobiology of addiction may reduce the stigma associated with AUD, helping reframe the issue as a “health condition, rather than as a moral failing,” Dr. Koob said.
Stigma remains a major barrier to AUD treatment, he added, explaining that factors contributing to stigma include shame patients may feel for what they perceive as a personal failure, and lack of knowledge about treatment options.
Separating AUD treatment from primary care exacerbates that problem, perpetuating the sense that AUD is somehow a “different” kind of issue, he said.
Health care clinicians in primary care can help alleviate the stigma by engaging in screening and offering referral to treatment, he said, adding that the NIAAA offers a navigator website designed to help individuals negotiate the process of choosing a treatment approach for AUD.
Language matters, according to Dr. Koob, who suggested using nonstigmatizing “person-first” terminology to refer to affected individuals not as alcoholics, but as “persons with AUD.”
Challenges ahead for AUD
There’s still a lot of work to be done to understand differences in alcohol pathology between men and women, especially as gaps narrow between the sexes for AUD incidence, early-onset drinking, frequency and intensity of drinking, and self-reported consequences, Dr. Koob said.
Age differences are also important to study. On one hand, older individuals appear to be more sensitive to the effects of alcohol, he said, because of metabolism changes, neurocognitive decline, and “inflamm-aging,” or the chronic and low level inflammatory state associated with aging.
Adolescents are also an increased-risk population of research interest, since brain wiring connections are “particularly sensitive” to alcohol in the teen years, potentially setting up changes in vulnerability to AUD that last into adulthood.
Other challenges include the unmet need for better and more individualized AUD treatments, the issue of alcohol tolerance, which Dr. Koob said has been “ignored for many years” by researchers, the contribution of pain to AUD, and the way that dysregulated sleep contributes to AUD, and vice versa.
Research likewise remains “challenging” regarding conditions that are frequently found in conjunction with AUD, such as major depressive episodes, anxiety disorders, and posttraumatic stress disorder: “These are all areas that we’re intensely interested in as comorbidities with AUD,” Dr. Koob said.
Dr. Koob reported no disclosures.
SOURCE: Koob GF. APA 2020, Abstract.
FROM APA 2020
Percentage of Psychiatrists Doing Psychotherapy Dwindles
PHILADELPHIA – The practice of psychotherapy by psychiatrists dropped by 20 percentage points from 2002 to 2010, in large part because of low reimbursement levels and the inability of many patients to afford psychotherapy sessions out of pocket, based on results from a 2010 survey completed by 394 practicing psychiatrists.
The survey results did not address the extent to which the psychotherapy that psychiatrists no longer provide has been replaced by sessions with other types of psychotherapy providers, Joyce C. West, Ph.D., said at the annual meeting of the American Psychiatric Association. "The trend is for psychiatrists to be team leaders" in caring for psychiatric patients, and for psychiatrists to "make referrals for psychotherapy to other team members," said Dr. West, director of policy research at the American Psychiatric Institute for Research and Education in Arlington, Va.
In contrast, during the same period, psychiatrists embraced pharmacotherapy more tightly, with the use of drug therapy rising to 89% of responding psychiatrists in 2010, up from 81% in 2002 and from 54% in 1988.
Growth in the availability of psychotherapy from nonpsychiatrists helped keep psychotherapy available. "There clearly is a strong evidence base for [the efficacy of] psychotherapy, and patients with resources [to pay for it themselves] are more likely to want psychotherapy," she noted.
The survey results and other recent psychotherapy assessments document a shift in who delivers psychotherapy. "The percentage of the population receiving psychotherapy in a year has not significantly lowered," at 3.18% of the U.S. population in 2007, essentially unchanged from the 3.37% rate in 1998. "However, there was a decline in psychiatrists providing psychotherapy; more patients of psychiatrists received medications, rising from 44% in 2002 to 57% in 2010. It appears that psychotherapy increasingly shifted away from psychiatrists, while other professions provided it," said Dr. John Christopher Perry, a coinvestigator with Dr. West on the survey, and a professor of psychiatry at McGill University in Montreal.
Is it okay if a steady number of patients has access to psychotherapy, but that it increasingly comes from nonpsychiatrists? "Psychotherapy is a core discipline in psychiatry, but it is shared with other professions. Understanding the mind and body, and understanding how intervening with one affects the other is an approach that is unique to psychiatry.
"If psychiatrists shift to mostly being diagnosticians and prescribers, we will lose this and become less knowledgeable about understanding and helping people. When a psychiatrist only manages medications and someone else provides psychotherapy, it limits the view of a patient’s symptoms, and may lead to overprescribing. When the psychiatrist is also the therapist, there is better opportunity to deal with life stress, coping, and distress without relying primarily or solely on prescribing," said Dr. Perry, who is also director of psychotherapy research at Jewish General Hospital in Montreal.
To examine how psychiatrists used psychotherapy in 2010, Dr. West, Dr. Perry, and their associates sent a 36-item questionnaire on the subject to a random sample of 3,000 members of the American Psychiatric Association, excluding medical students and residents. The researchers received completed surveys from 394 practicing psychiatrists. The respondents averaged 54 years old, two-thirds were men, 83% were white, and half were in private practice. Each psychiatrist saw an average of 42 patients in a typical week.
When asked how they treated patients during their most recent typical week, 48% said that they used psychotherapy and 89% said that they used pharmacotherapy – either in combination or as monotherapy – in an analysis that weighted responses based on the number of patients each psychiatrist treated. For psychotherapy, the 48% prevalence of use compared with 68% in a 2002 survey and 72% in a 1988 survey. The drug therapy rate of 89% in 2010 compared with 81% in 2002 and 54% in 1988.
When asked what barriers they encountered when performing psychotherapy, 80% of responding psychiatrists cited financial barriers, and 72% noted administrative barriers. Financial barriers included an inability of patients to afford psychotherapy sessions themselves, and low reimbursement rates from third-party payers. Administrative barriers included dealing with insurance companies and writing treatment notes.
Half the responding psychiatrists also cited pressure to treat psychotherapy patients in shorter sessions and with fewer sessions, and 48% reported pressure to spend more time focused on diagnosis and on pharmacologic consultations. Just over half the respondents said their practice of psychotherapy would increase if the reimbursement level approached that for pharmacotherapy.
Responding psychiatrists found pharmacotherapy somewhat more effective, with 87% saying they were satisfied with the efficacy or helpfulness of pharmacotherapy, compared with 76% who had the same assessment of psychotherapy.
Reimbursement patterns for psychotherapy are in flux, noted Dr. Perry. In both the United States and Canada, health care payers "tend to undervalue psychotherapy relative to consultation and medication management." As a consequence, "more and more providers do not accept insurance or avoid certain types of insurance such as Medicare and Medicaid" for psychotherapy. Another reimbursement issue is payers’ deciding "who gets how much psychotherapy," Dr. Perry said. "I pray that a creative group of psychiatrists, health economists, and public health people, along with some government input, comes up with alternatives.
"Clearly, no one [reimbursement] system will work for every patient who needs psychotherapy."
Dr. West and Dr. Perry said they had no disclosures.
PHILADELPHIA – The practice of psychotherapy by psychiatrists dropped by 20 percentage points from 2002 to 2010, in large part because of low reimbursement levels and the inability of many patients to afford psychotherapy sessions out of pocket, based on results from a 2010 survey completed by 394 practicing psychiatrists.
The survey results did not address the extent to which the psychotherapy that psychiatrists no longer provide has been replaced by sessions with other types of psychotherapy providers, Joyce C. West, Ph.D., said at the annual meeting of the American Psychiatric Association. "The trend is for psychiatrists to be team leaders" in caring for psychiatric patients, and for psychiatrists to "make referrals for psychotherapy to other team members," said Dr. West, director of policy research at the American Psychiatric Institute for Research and Education in Arlington, Va.
In contrast, during the same period, psychiatrists embraced pharmacotherapy more tightly, with the use of drug therapy rising to 89% of responding psychiatrists in 2010, up from 81% in 2002 and from 54% in 1988.
Growth in the availability of psychotherapy from nonpsychiatrists helped keep psychotherapy available. "There clearly is a strong evidence base for [the efficacy of] psychotherapy, and patients with resources [to pay for it themselves] are more likely to want psychotherapy," she noted.
The survey results and other recent psychotherapy assessments document a shift in who delivers psychotherapy. "The percentage of the population receiving psychotherapy in a year has not significantly lowered," at 3.18% of the U.S. population in 2007, essentially unchanged from the 3.37% rate in 1998. "However, there was a decline in psychiatrists providing psychotherapy; more patients of psychiatrists received medications, rising from 44% in 2002 to 57% in 2010. It appears that psychotherapy increasingly shifted away from psychiatrists, while other professions provided it," said Dr. John Christopher Perry, a coinvestigator with Dr. West on the survey, and a professor of psychiatry at McGill University in Montreal.
Is it okay if a steady number of patients has access to psychotherapy, but that it increasingly comes from nonpsychiatrists? "Psychotherapy is a core discipline in psychiatry, but it is shared with other professions. Understanding the mind and body, and understanding how intervening with one affects the other is an approach that is unique to psychiatry.
"If psychiatrists shift to mostly being diagnosticians and prescribers, we will lose this and become less knowledgeable about understanding and helping people. When a psychiatrist only manages medications and someone else provides psychotherapy, it limits the view of a patient’s symptoms, and may lead to overprescribing. When the psychiatrist is also the therapist, there is better opportunity to deal with life stress, coping, and distress without relying primarily or solely on prescribing," said Dr. Perry, who is also director of psychotherapy research at Jewish General Hospital in Montreal.
To examine how psychiatrists used psychotherapy in 2010, Dr. West, Dr. Perry, and their associates sent a 36-item questionnaire on the subject to a random sample of 3,000 members of the American Psychiatric Association, excluding medical students and residents. The researchers received completed surveys from 394 practicing psychiatrists. The respondents averaged 54 years old, two-thirds were men, 83% were white, and half were in private practice. Each psychiatrist saw an average of 42 patients in a typical week.
When asked how they treated patients during their most recent typical week, 48% said that they used psychotherapy and 89% said that they used pharmacotherapy – either in combination or as monotherapy – in an analysis that weighted responses based on the number of patients each psychiatrist treated. For psychotherapy, the 48% prevalence of use compared with 68% in a 2002 survey and 72% in a 1988 survey. The drug therapy rate of 89% in 2010 compared with 81% in 2002 and 54% in 1988.
When asked what barriers they encountered when performing psychotherapy, 80% of responding psychiatrists cited financial barriers, and 72% noted administrative barriers. Financial barriers included an inability of patients to afford psychotherapy sessions themselves, and low reimbursement rates from third-party payers. Administrative barriers included dealing with insurance companies and writing treatment notes.
Half the responding psychiatrists also cited pressure to treat psychotherapy patients in shorter sessions and with fewer sessions, and 48% reported pressure to spend more time focused on diagnosis and on pharmacologic consultations. Just over half the respondents said their practice of psychotherapy would increase if the reimbursement level approached that for pharmacotherapy.
Responding psychiatrists found pharmacotherapy somewhat more effective, with 87% saying they were satisfied with the efficacy or helpfulness of pharmacotherapy, compared with 76% who had the same assessment of psychotherapy.
Reimbursement patterns for psychotherapy are in flux, noted Dr. Perry. In both the United States and Canada, health care payers "tend to undervalue psychotherapy relative to consultation and medication management." As a consequence, "more and more providers do not accept insurance or avoid certain types of insurance such as Medicare and Medicaid" for psychotherapy. Another reimbursement issue is payers’ deciding "who gets how much psychotherapy," Dr. Perry said. "I pray that a creative group of psychiatrists, health economists, and public health people, along with some government input, comes up with alternatives.
"Clearly, no one [reimbursement] system will work for every patient who needs psychotherapy."
Dr. West and Dr. Perry said they had no disclosures.
PHILADELPHIA – The practice of psychotherapy by psychiatrists dropped by 20 percentage points from 2002 to 2010, in large part because of low reimbursement levels and the inability of many patients to afford psychotherapy sessions out of pocket, based on results from a 2010 survey completed by 394 practicing psychiatrists.
The survey results did not address the extent to which the psychotherapy that psychiatrists no longer provide has been replaced by sessions with other types of psychotherapy providers, Joyce C. West, Ph.D., said at the annual meeting of the American Psychiatric Association. "The trend is for psychiatrists to be team leaders" in caring for psychiatric patients, and for psychiatrists to "make referrals for psychotherapy to other team members," said Dr. West, director of policy research at the American Psychiatric Institute for Research and Education in Arlington, Va.
In contrast, during the same period, psychiatrists embraced pharmacotherapy more tightly, with the use of drug therapy rising to 89% of responding psychiatrists in 2010, up from 81% in 2002 and from 54% in 1988.
Growth in the availability of psychotherapy from nonpsychiatrists helped keep psychotherapy available. "There clearly is a strong evidence base for [the efficacy of] psychotherapy, and patients with resources [to pay for it themselves] are more likely to want psychotherapy," she noted.
The survey results and other recent psychotherapy assessments document a shift in who delivers psychotherapy. "The percentage of the population receiving psychotherapy in a year has not significantly lowered," at 3.18% of the U.S. population in 2007, essentially unchanged from the 3.37% rate in 1998. "However, there was a decline in psychiatrists providing psychotherapy; more patients of psychiatrists received medications, rising from 44% in 2002 to 57% in 2010. It appears that psychotherapy increasingly shifted away from psychiatrists, while other professions provided it," said Dr. John Christopher Perry, a coinvestigator with Dr. West on the survey, and a professor of psychiatry at McGill University in Montreal.
Is it okay if a steady number of patients has access to psychotherapy, but that it increasingly comes from nonpsychiatrists? "Psychotherapy is a core discipline in psychiatry, but it is shared with other professions. Understanding the mind and body, and understanding how intervening with one affects the other is an approach that is unique to psychiatry.
"If psychiatrists shift to mostly being diagnosticians and prescribers, we will lose this and become less knowledgeable about understanding and helping people. When a psychiatrist only manages medications and someone else provides psychotherapy, it limits the view of a patient’s symptoms, and may lead to overprescribing. When the psychiatrist is also the therapist, there is better opportunity to deal with life stress, coping, and distress without relying primarily or solely on prescribing," said Dr. Perry, who is also director of psychotherapy research at Jewish General Hospital in Montreal.
To examine how psychiatrists used psychotherapy in 2010, Dr. West, Dr. Perry, and their associates sent a 36-item questionnaire on the subject to a random sample of 3,000 members of the American Psychiatric Association, excluding medical students and residents. The researchers received completed surveys from 394 practicing psychiatrists. The respondents averaged 54 years old, two-thirds were men, 83% were white, and half were in private practice. Each psychiatrist saw an average of 42 patients in a typical week.
When asked how they treated patients during their most recent typical week, 48% said that they used psychotherapy and 89% said that they used pharmacotherapy – either in combination or as monotherapy – in an analysis that weighted responses based on the number of patients each psychiatrist treated. For psychotherapy, the 48% prevalence of use compared with 68% in a 2002 survey and 72% in a 1988 survey. The drug therapy rate of 89% in 2010 compared with 81% in 2002 and 54% in 1988.
When asked what barriers they encountered when performing psychotherapy, 80% of responding psychiatrists cited financial barriers, and 72% noted administrative barriers. Financial barriers included an inability of patients to afford psychotherapy sessions themselves, and low reimbursement rates from third-party payers. Administrative barriers included dealing with insurance companies and writing treatment notes.
Half the responding psychiatrists also cited pressure to treat psychotherapy patients in shorter sessions and with fewer sessions, and 48% reported pressure to spend more time focused on diagnosis and on pharmacologic consultations. Just over half the respondents said their practice of psychotherapy would increase if the reimbursement level approached that for pharmacotherapy.
Responding psychiatrists found pharmacotherapy somewhat more effective, with 87% saying they were satisfied with the efficacy or helpfulness of pharmacotherapy, compared with 76% who had the same assessment of psychotherapy.
Reimbursement patterns for psychotherapy are in flux, noted Dr. Perry. In both the United States and Canada, health care payers "tend to undervalue psychotherapy relative to consultation and medication management." As a consequence, "more and more providers do not accept insurance or avoid certain types of insurance such as Medicare and Medicaid" for psychotherapy. Another reimbursement issue is payers’ deciding "who gets how much psychotherapy," Dr. Perry said. "I pray that a creative group of psychiatrists, health economists, and public health people, along with some government input, comes up with alternatives.
"Clearly, no one [reimbursement] system will work for every patient who needs psychotherapy."
Dr. West and Dr. Perry said they had no disclosures.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: In 2010, 48% of U.S. psychiatrists who completed a survey reported performing psychotherapy on patients, down from 68% in 2002.
Data Source: Data came from survey results collected from 394 practicing, U.S. psychiatrists who were members of the American Psychiatric Association.
Disclosures: Dr. West and Dr. Perry said they had no disclosures.
New Device Cuts Fibromyalgia Pain in Pilot Study
PHILADELPHIA – An investigational, four-coil device for transcranial magnetic stimulation deep in the brain produced some striking cases of sustained pain relief when it was tested on five fibromyalgia patients in a pilot study.
Based on these promising early results, the next step will be a larger, controlled study, involving about 40 fibromyalgia patients, Dr. M. Bret Schneider said at the annual meeting of the American Psychiatric Association.
The new device for repetitive transcranial magnetic stimulation (rTMS) builds on the premise of a TMS device marketed by NeuroStar and approved by the Food and Drug Administration for treating depression. Instead of the single coil used in the NeuroStar device to create a pulsating magnetic field and produce an electrical current within a patient’s prefrontal cortex, Dr. Schneider and his associates designed a four-coil device to target a deeper brain region, much like a Gamma Knife used for radiosurgery. Their target was the dorsal anterior cingulate, a region of the brain linked with chronic pain. The concept was to stimulate the cingulate to produce a noninvasive cingulotomy, a surgical procedure occasionally performed to sever white-matter connections to the cingulate and provide pain relief to patients with intractable, chronic pain.
Dr. Schneider cofounded a company (Cervel Neurotech) to develop this device. The first step was to test several different four-coil arrays on healthy volunteers to identify the orientation that appeared to produce the greatest effect within the dorsal anterior cingulate, based on the treatment’s impact on cingulate metabolism measured with oxygen-15 PET scanning.
The developers next took the most promising orientation and applied it using two different treatment modes in a study that included a total of 45 fibromyalgia patients with chronic, intractable pain. Some patients in the study received treatments with a different coil orientation, or sham treatments.
The best results occurred in five patients who received the highest frequency of magnetic pulses, 10 Hz in the best-performing coil orientation. These patients had a treatment course that involved 10 pulses per second for 4 seconds, followed by a 26-second pause, and then a repeat. Each daily treatment session included 75 of these repeated courses (a total treatment time of 37.5 minutes). Patients received this daily session 5 days a week for 4 weeks, and then their residual pain levels off treatment were measured using the BPI (Brief Pain Inventory) 3 days after their last session, and then 4 weeks after their last treatment session. The researchers also performed BPI measures on each patient at baseline, and on each of the 20 days when each patient underwent treatment.
The results showed that all five patients averaged a steady drop in their pain levels over the course of the 4-week treatment, and that their pain fell even further when measured after their treatment finished. Their lowest pain level occurred at the 4-week follow-up, when they showed an overall average 45% drop in their pain scores, compared with baseline. Individually, "some of the patients had complete pain relief, while others less so," said Dr. Schneider, who is also a psychiatrist and neurosurgeon at Stanford (Calif.) University.
The treatment appeared safe, with fewer adverse effects reported by patients who received any of the active treatments, compared with those who received sham treatments. The most common, treatment-associated adverse effects were mild episodes of headache, nausea, and scalp pain, he said.
The presumed mechanism of action is that the sessions of rTMS produce long-term potentiation in the cingulate, Dr. Schneider said in an interview. During rTMS treatment, neurons in the cingulate rapidly fire, but once treatment stops, the activity in the cingulate appears to fall below the basal level. The researchers documented this with their 15O PET studies, which showed that following rTMS, the dorsal anterior cingulate has reduced blood flow and metabolic activity. This reduced cingulate activity might explain the pain relief that patients reported, Dr. Schneider said.
The study was funded by Cervel Neurotech, the company developing this new device. Dr. Schneider is a founder, employee, and stockholder of the company.
PHILADELPHIA – An investigational, four-coil device for transcranial magnetic stimulation deep in the brain produced some striking cases of sustained pain relief when it was tested on five fibromyalgia patients in a pilot study.
Based on these promising early results, the next step will be a larger, controlled study, involving about 40 fibromyalgia patients, Dr. M. Bret Schneider said at the annual meeting of the American Psychiatric Association.
The new device for repetitive transcranial magnetic stimulation (rTMS) builds on the premise of a TMS device marketed by NeuroStar and approved by the Food and Drug Administration for treating depression. Instead of the single coil used in the NeuroStar device to create a pulsating magnetic field and produce an electrical current within a patient’s prefrontal cortex, Dr. Schneider and his associates designed a four-coil device to target a deeper brain region, much like a Gamma Knife used for radiosurgery. Their target was the dorsal anterior cingulate, a region of the brain linked with chronic pain. The concept was to stimulate the cingulate to produce a noninvasive cingulotomy, a surgical procedure occasionally performed to sever white-matter connections to the cingulate and provide pain relief to patients with intractable, chronic pain.
Dr. Schneider cofounded a company (Cervel Neurotech) to develop this device. The first step was to test several different four-coil arrays on healthy volunteers to identify the orientation that appeared to produce the greatest effect within the dorsal anterior cingulate, based on the treatment’s impact on cingulate metabolism measured with oxygen-15 PET scanning.
The developers next took the most promising orientation and applied it using two different treatment modes in a study that included a total of 45 fibromyalgia patients with chronic, intractable pain. Some patients in the study received treatments with a different coil orientation, or sham treatments.
The best results occurred in five patients who received the highest frequency of magnetic pulses, 10 Hz in the best-performing coil orientation. These patients had a treatment course that involved 10 pulses per second for 4 seconds, followed by a 26-second pause, and then a repeat. Each daily treatment session included 75 of these repeated courses (a total treatment time of 37.5 minutes). Patients received this daily session 5 days a week for 4 weeks, and then their residual pain levels off treatment were measured using the BPI (Brief Pain Inventory) 3 days after their last session, and then 4 weeks after their last treatment session. The researchers also performed BPI measures on each patient at baseline, and on each of the 20 days when each patient underwent treatment.
The results showed that all five patients averaged a steady drop in their pain levels over the course of the 4-week treatment, and that their pain fell even further when measured after their treatment finished. Their lowest pain level occurred at the 4-week follow-up, when they showed an overall average 45% drop in their pain scores, compared with baseline. Individually, "some of the patients had complete pain relief, while others less so," said Dr. Schneider, who is also a psychiatrist and neurosurgeon at Stanford (Calif.) University.
The treatment appeared safe, with fewer adverse effects reported by patients who received any of the active treatments, compared with those who received sham treatments. The most common, treatment-associated adverse effects were mild episodes of headache, nausea, and scalp pain, he said.
The presumed mechanism of action is that the sessions of rTMS produce long-term potentiation in the cingulate, Dr. Schneider said in an interview. During rTMS treatment, neurons in the cingulate rapidly fire, but once treatment stops, the activity in the cingulate appears to fall below the basal level. The researchers documented this with their 15O PET studies, which showed that following rTMS, the dorsal anterior cingulate has reduced blood flow and metabolic activity. This reduced cingulate activity might explain the pain relief that patients reported, Dr. Schneider said.
The study was funded by Cervel Neurotech, the company developing this new device. Dr. Schneider is a founder, employee, and stockholder of the company.
PHILADELPHIA – An investigational, four-coil device for transcranial magnetic stimulation deep in the brain produced some striking cases of sustained pain relief when it was tested on five fibromyalgia patients in a pilot study.
Based on these promising early results, the next step will be a larger, controlled study, involving about 40 fibromyalgia patients, Dr. M. Bret Schneider said at the annual meeting of the American Psychiatric Association.
The new device for repetitive transcranial magnetic stimulation (rTMS) builds on the premise of a TMS device marketed by NeuroStar and approved by the Food and Drug Administration for treating depression. Instead of the single coil used in the NeuroStar device to create a pulsating magnetic field and produce an electrical current within a patient’s prefrontal cortex, Dr. Schneider and his associates designed a four-coil device to target a deeper brain region, much like a Gamma Knife used for radiosurgery. Their target was the dorsal anterior cingulate, a region of the brain linked with chronic pain. The concept was to stimulate the cingulate to produce a noninvasive cingulotomy, a surgical procedure occasionally performed to sever white-matter connections to the cingulate and provide pain relief to patients with intractable, chronic pain.
Dr. Schneider cofounded a company (Cervel Neurotech) to develop this device. The first step was to test several different four-coil arrays on healthy volunteers to identify the orientation that appeared to produce the greatest effect within the dorsal anterior cingulate, based on the treatment’s impact on cingulate metabolism measured with oxygen-15 PET scanning.
The developers next took the most promising orientation and applied it using two different treatment modes in a study that included a total of 45 fibromyalgia patients with chronic, intractable pain. Some patients in the study received treatments with a different coil orientation, or sham treatments.
The best results occurred in five patients who received the highest frequency of magnetic pulses, 10 Hz in the best-performing coil orientation. These patients had a treatment course that involved 10 pulses per second for 4 seconds, followed by a 26-second pause, and then a repeat. Each daily treatment session included 75 of these repeated courses (a total treatment time of 37.5 minutes). Patients received this daily session 5 days a week for 4 weeks, and then their residual pain levels off treatment were measured using the BPI (Brief Pain Inventory) 3 days after their last session, and then 4 weeks after their last treatment session. The researchers also performed BPI measures on each patient at baseline, and on each of the 20 days when each patient underwent treatment.
The results showed that all five patients averaged a steady drop in their pain levels over the course of the 4-week treatment, and that their pain fell even further when measured after their treatment finished. Their lowest pain level occurred at the 4-week follow-up, when they showed an overall average 45% drop in their pain scores, compared with baseline. Individually, "some of the patients had complete pain relief, while others less so," said Dr. Schneider, who is also a psychiatrist and neurosurgeon at Stanford (Calif.) University.
The treatment appeared safe, with fewer adverse effects reported by patients who received any of the active treatments, compared with those who received sham treatments. The most common, treatment-associated adverse effects were mild episodes of headache, nausea, and scalp pain, he said.
The presumed mechanism of action is that the sessions of rTMS produce long-term potentiation in the cingulate, Dr. Schneider said in an interview. During rTMS treatment, neurons in the cingulate rapidly fire, but once treatment stops, the activity in the cingulate appears to fall below the basal level. The researchers documented this with their 15O PET studies, which showed that following rTMS, the dorsal anterior cingulate has reduced blood flow and metabolic activity. This reduced cingulate activity might explain the pain relief that patients reported, Dr. Schneider said.
The study was funded by Cervel Neurotech, the company developing this new device. Dr. Schneider is a founder, employee, and stockholder of the company.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: Patients with chronic fibromyalgia pain averaged a 45% pain-score cut following treatment with transcranial magnetic stimulation.
Data Source: Data came from five patients with chronic fibromyalgia pain treated with a specific transcranial magnetic stimulation coil orientation.
Disclosures: The study was funded by Cervel Neurotech, the company developing the new device. Dr. Schneider is a founder, employee, and stockholder of the company.
Hospitalist Model Improves Acute Psychiatric Care
PHILADELPHIA – Switching physician coverage in a hospital’s acute-care psychiatric ward from 13 consultant psychiatrists to a single, full-time hospitalist psychiatrist led to significant care improvements and reduced costs.
Perhaps the most striking benefit from the staffing switch was in average patient length of stay, which dropped by about half, Dr. Julian Beezhold said at the meeting. Average length of stay fell from nearly 22 days before the staffing change to about 11 days. "The reduced length of stay made a huge impact on cost savings." In addition, "the evidence is overwhelming that patient outcomes were better" following the change, said Dr. Beezhold, chief of psychiatry at Norfolk and Waveney Mental Health in Norwich, U.K.
Taking into account all the outcome changes produced by the switch to hospitalist-based psychiatric care, the study provides "overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold concluded.
The Psychiatric Hospitalist Network Evaluation Study included 5,019 patients admitted to the hospital for an acute psychiatric condition in 2002-2010, during the 42 months before and 42 months after Norfolk and Waveney switched from relying on 13 consultant psychiatrists to having one hospitalist psychiatrist who either directly administered or supervised all psychiatric admissions and in-hospital management. As a control, the study used data collected from a second psychiatric ward at the hospital that treated similar patients from a different geographic region. The control ward remained on the hospitalist model for psychiatric care throughout the study period.
The patients averaged about 40 years old, and slightly more than half were men. The most common psychiatric diagnosis was psychosis, in a quarter to a third of the admitted patients, followed by bipolar disorder and depression.
To analyze outcomes, Dr. Beezhold and his associates compared outcome rates before and after the model change in the study ward, and compared the extent of change with what occurred in the control ward, which did not change its staffing model. For 15 of the 20 outcomes assessed, the test ward that switched from a consultant model to a hospitalist model had significantly better changes compared with the control ward.
The staffing change led to reductions in deaths, violent episodes, deliberate self-harm, staff accidents, and patient accidents, while the ward that had no change showed similar rates, smaller decreases, or even increases from the before to after periods. For example, the rate of all incidents per admission fell by a statistically significant 48% from the before to after period in the ward that switched to hospitalist care, which the same measure had a statistically not-significant, 4% rise from before to after in the control ward. The rate of deliberate self-harm per admission fell by a statistically significant 76% from before to after in the ward that switched to hospitalist care, while the same measure showed a statistically non-significant decline in the control ward.
The results are likely widely generalizable since they came from an observational study of routine, community practice that had no patient exclusions, Dr. Beezhold said.
Dr. Beezhold said he had no disclosures.
PHILADELPHIA – Switching physician coverage in a hospital’s acute-care psychiatric ward from 13 consultant psychiatrists to a single, full-time hospitalist psychiatrist led to significant care improvements and reduced costs.
Perhaps the most striking benefit from the staffing switch was in average patient length of stay, which dropped by about half, Dr. Julian Beezhold said at the meeting. Average length of stay fell from nearly 22 days before the staffing change to about 11 days. "The reduced length of stay made a huge impact on cost savings." In addition, "the evidence is overwhelming that patient outcomes were better" following the change, said Dr. Beezhold, chief of psychiatry at Norfolk and Waveney Mental Health in Norwich, U.K.
Taking into account all the outcome changes produced by the switch to hospitalist-based psychiatric care, the study provides "overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold concluded.
The Psychiatric Hospitalist Network Evaluation Study included 5,019 patients admitted to the hospital for an acute psychiatric condition in 2002-2010, during the 42 months before and 42 months after Norfolk and Waveney switched from relying on 13 consultant psychiatrists to having one hospitalist psychiatrist who either directly administered or supervised all psychiatric admissions and in-hospital management. As a control, the study used data collected from a second psychiatric ward at the hospital that treated similar patients from a different geographic region. The control ward remained on the hospitalist model for psychiatric care throughout the study period.
The patients averaged about 40 years old, and slightly more than half were men. The most common psychiatric diagnosis was psychosis, in a quarter to a third of the admitted patients, followed by bipolar disorder and depression.
To analyze outcomes, Dr. Beezhold and his associates compared outcome rates before and after the model change in the study ward, and compared the extent of change with what occurred in the control ward, which did not change its staffing model. For 15 of the 20 outcomes assessed, the test ward that switched from a consultant model to a hospitalist model had significantly better changes compared with the control ward.
The staffing change led to reductions in deaths, violent episodes, deliberate self-harm, staff accidents, and patient accidents, while the ward that had no change showed similar rates, smaller decreases, or even increases from the before to after periods. For example, the rate of all incidents per admission fell by a statistically significant 48% from the before to after period in the ward that switched to hospitalist care, which the same measure had a statistically not-significant, 4% rise from before to after in the control ward. The rate of deliberate self-harm per admission fell by a statistically significant 76% from before to after in the ward that switched to hospitalist care, while the same measure showed a statistically non-significant decline in the control ward.
The results are likely widely generalizable since they came from an observational study of routine, community practice that had no patient exclusions, Dr. Beezhold said.
Dr. Beezhold said he had no disclosures.
PHILADELPHIA – Switching physician coverage in a hospital’s acute-care psychiatric ward from 13 consultant psychiatrists to a single, full-time hospitalist psychiatrist led to significant care improvements and reduced costs.
Perhaps the most striking benefit from the staffing switch was in average patient length of stay, which dropped by about half, Dr. Julian Beezhold said at the meeting. Average length of stay fell from nearly 22 days before the staffing change to about 11 days. "The reduced length of stay made a huge impact on cost savings." In addition, "the evidence is overwhelming that patient outcomes were better" following the change, said Dr. Beezhold, chief of psychiatry at Norfolk and Waveney Mental Health in Norwich, U.K.
Taking into account all the outcome changes produced by the switch to hospitalist-based psychiatric care, the study provides "overwhelming, robust evidence showing clear benefit from a hospitalist model of care," Dr. Beezhold concluded.
The Psychiatric Hospitalist Network Evaluation Study included 5,019 patients admitted to the hospital for an acute psychiatric condition in 2002-2010, during the 42 months before and 42 months after Norfolk and Waveney switched from relying on 13 consultant psychiatrists to having one hospitalist psychiatrist who either directly administered or supervised all psychiatric admissions and in-hospital management. As a control, the study used data collected from a second psychiatric ward at the hospital that treated similar patients from a different geographic region. The control ward remained on the hospitalist model for psychiatric care throughout the study period.
The patients averaged about 40 years old, and slightly more than half were men. The most common psychiatric diagnosis was psychosis, in a quarter to a third of the admitted patients, followed by bipolar disorder and depression.
To analyze outcomes, Dr. Beezhold and his associates compared outcome rates before and after the model change in the study ward, and compared the extent of change with what occurred in the control ward, which did not change its staffing model. For 15 of the 20 outcomes assessed, the test ward that switched from a consultant model to a hospitalist model had significantly better changes compared with the control ward.
The staffing change led to reductions in deaths, violent episodes, deliberate self-harm, staff accidents, and patient accidents, while the ward that had no change showed similar rates, smaller decreases, or even increases from the before to after periods. For example, the rate of all incidents per admission fell by a statistically significant 48% from the before to after period in the ward that switched to hospitalist care, which the same measure had a statistically not-significant, 4% rise from before to after in the control ward. The rate of deliberate self-harm per admission fell by a statistically significant 76% from before to after in the ward that switched to hospitalist care, while the same measure showed a statistically non-significant decline in the control ward.
The results are likely widely generalizable since they came from an observational study of routine, community practice that had no patient exclusions, Dr. Beezhold said.
Dr. Beezhold said he had no disclosures.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: Changing an acute psychiatric ward’s staffing from 13 attendings to one hospitalist produced a significant, 50% cut in length of stay.
Data Source: Data came from a review of 5,019 acute psychiatric patients treated in either of two wards at a U.K. hospital.
Disclosures: Dr. Beezhold said he had no disclosures.
Depot Injection Boosts Antipsychotic Compliance in Schizophrenia
PHILADELPHIA – Long-acting, injectable formulations of antipsychotic drugs significantly boosted treatment compliance in patients with schizophrenia in a review of reimbursement records for more than 3,600 patients.
The increased compliance achieved with depot administration of antipsychotic medications makes it an attractive alternative to oral administration of antipsychotic drugs to patients with schizophrenia, Dr. Bruce J. Wong said at the meeting.
Greater use of depot medications could improve the management of patients with schizophrenia because treatment compliance is a major determinant of the ongoing health of schizophrenia patients, said Dr. Wong, a consultant clinical epidemiologist in Wayne, Pa.
"Lack of patient adherence to psychotropic medications is the single largest factor contributing to the ongoing morbidity of schizophrenia today. Even short gaps in antipsychotic usage increase the risk of rehospitalization" of patients, said Dr. Wong, also of the department of biostatistics and epidemiology at the University of Pennsylvania, Philadelphia.
"In practice today, depot, injected antipsychotic medications are secondary treatments, used almost like punishment when patients are noncompliant with oral drugs but should be viewed more like a reward," he said. The same drugs are formulated into oral and injectable preparations, so depot versions are not less effective or less safe than oral forms. Instead, a series of social factors relegate injectable formulations to second-line status: needle phobia in patients, a modest amount of pain that can occur when antipsychotic drugs are injected into muscle, the lack of comfort that psychiatrists often have with performing injections, and the need for a psychiatrist to obtain and have the drug on hand as opposed to the convenience of writing a prescription for the patient to get the oral form.
None of these alone is a major barrier, but together they seem to create enough of a roadblock to make injections less favored, Dr. Wong said in an interview.
To better document how the two delivery options relate to compliance, Dr. Wong and his associates used data collected on 3,004 commercially insured patients with schizophrenia in the MarketScan database of Thompson Reuters, and on 665 Medicare patients collected by the Center for Medicare and Medicaid Services during January 2005 to September 2010. The analysis focused on patients who began treatment with either an oral or a long-acting injected formulation of an antipsychotic drug, and who had at least 12 months of continuous health coverage prior to the index prescription.
In the commercial group, 13% of patients received an incident prescription for an injectable formulation, and 87% received an incident prescription for an oral antipsychotic. In the Medicare group, 22% filled a first-time prescription for a depot, injected formulation, and 78% fell into the oral group.
During follow-up, the researchers measured compliance by the average level of patients’ medication possession ratio. For patients taking an oral drug, this was determined by how many days during follow-up patients had their prescribed medication based on their history of filling their prescription. For patients receiving an injected drug, Dr. Wong and his associates calculated a medication possession ratio based on the frequency at which a patient’s records documented receiving an injection, and the number of days the injection covered during follow-up.
Among commercially insured patients, those who received injections had an average 67% medication possession ratio, compared with a 56% rate among patients taking an oral drug. In the Medicare group, injected patients had a 68% possession ratio, compared with 59% in those on an oral drug. In both subgroups the difference in ratios between the two types of treatment were statistically significant.
The analyses also identified other differences between the two treatment groups. Among the commercially insured, injected drugs were significantly more common than oral drugs in patients treated in comprehensive health plans, while injected drugs were used significantly less often than oral drugs in health maintenance organization settings.
Among commercially insured patients, those who received long-acting injections averaged 42 years old, significantly older than those who received oral drugs, who averaged 37 years old. Dr. Wong attributed this age difference to patients typically starting on an oral formulation and only switching to an injected formulation a few years later, once they showed that they were not reliable oral users. Medicare patients also showed a significant age difference, but the relationship flipped in this older age group. The mean age of the patients on injected antipsychotics was 67, while those on an oral drug averaged 73 years old. Dr. Wong said he did not have an explanation for this pattern among Medicare patients.
In the commercial group, patients on injected drugs were also significantly sicker, with an average Charlson comorbidity index of 0.58, compared with an average of 0.47 in the orally treated patients. Again, this pattern was reversed in Medicare patients, where the injected patients had an average Charlson comorbidity index score of 1.24, significantly less than the 1.83 average among patients on an oral drug.
The analysis also showed regional differences in the use of the two treatment options, with injections exceeding oral drug use in the North-Central U.S. region, while oral drugs were substantially more popular than injected drugs in the Western half of the United States. In other U.S. regions, the use of the two treatment routes was generally more balanced.
The study was sponsored by Otsuka, which markets the antipsychotic drug aripiprazole. Dr. Wong said he has been a consultant to Otsuka.
PHILADELPHIA – Long-acting, injectable formulations of antipsychotic drugs significantly boosted treatment compliance in patients with schizophrenia in a review of reimbursement records for more than 3,600 patients.
The increased compliance achieved with depot administration of antipsychotic medications makes it an attractive alternative to oral administration of antipsychotic drugs to patients with schizophrenia, Dr. Bruce J. Wong said at the meeting.
Greater use of depot medications could improve the management of patients with schizophrenia because treatment compliance is a major determinant of the ongoing health of schizophrenia patients, said Dr. Wong, a consultant clinical epidemiologist in Wayne, Pa.
"Lack of patient adherence to psychotropic medications is the single largest factor contributing to the ongoing morbidity of schizophrenia today. Even short gaps in antipsychotic usage increase the risk of rehospitalization" of patients, said Dr. Wong, also of the department of biostatistics and epidemiology at the University of Pennsylvania, Philadelphia.
"In practice today, depot, injected antipsychotic medications are secondary treatments, used almost like punishment when patients are noncompliant with oral drugs but should be viewed more like a reward," he said. The same drugs are formulated into oral and injectable preparations, so depot versions are not less effective or less safe than oral forms. Instead, a series of social factors relegate injectable formulations to second-line status: needle phobia in patients, a modest amount of pain that can occur when antipsychotic drugs are injected into muscle, the lack of comfort that psychiatrists often have with performing injections, and the need for a psychiatrist to obtain and have the drug on hand as opposed to the convenience of writing a prescription for the patient to get the oral form.
None of these alone is a major barrier, but together they seem to create enough of a roadblock to make injections less favored, Dr. Wong said in an interview.
To better document how the two delivery options relate to compliance, Dr. Wong and his associates used data collected on 3,004 commercially insured patients with schizophrenia in the MarketScan database of Thompson Reuters, and on 665 Medicare patients collected by the Center for Medicare and Medicaid Services during January 2005 to September 2010. The analysis focused on patients who began treatment with either an oral or a long-acting injected formulation of an antipsychotic drug, and who had at least 12 months of continuous health coverage prior to the index prescription.
In the commercial group, 13% of patients received an incident prescription for an injectable formulation, and 87% received an incident prescription for an oral antipsychotic. In the Medicare group, 22% filled a first-time prescription for a depot, injected formulation, and 78% fell into the oral group.
During follow-up, the researchers measured compliance by the average level of patients’ medication possession ratio. For patients taking an oral drug, this was determined by how many days during follow-up patients had their prescribed medication based on their history of filling their prescription. For patients receiving an injected drug, Dr. Wong and his associates calculated a medication possession ratio based on the frequency at which a patient’s records documented receiving an injection, and the number of days the injection covered during follow-up.
Among commercially insured patients, those who received injections had an average 67% medication possession ratio, compared with a 56% rate among patients taking an oral drug. In the Medicare group, injected patients had a 68% possession ratio, compared with 59% in those on an oral drug. In both subgroups the difference in ratios between the two types of treatment were statistically significant.
The analyses also identified other differences between the two treatment groups. Among the commercially insured, injected drugs were significantly more common than oral drugs in patients treated in comprehensive health plans, while injected drugs were used significantly less often than oral drugs in health maintenance organization settings.
Among commercially insured patients, those who received long-acting injections averaged 42 years old, significantly older than those who received oral drugs, who averaged 37 years old. Dr. Wong attributed this age difference to patients typically starting on an oral formulation and only switching to an injected formulation a few years later, once they showed that they were not reliable oral users. Medicare patients also showed a significant age difference, but the relationship flipped in this older age group. The mean age of the patients on injected antipsychotics was 67, while those on an oral drug averaged 73 years old. Dr. Wong said he did not have an explanation for this pattern among Medicare patients.
In the commercial group, patients on injected drugs were also significantly sicker, with an average Charlson comorbidity index of 0.58, compared with an average of 0.47 in the orally treated patients. Again, this pattern was reversed in Medicare patients, where the injected patients had an average Charlson comorbidity index score of 1.24, significantly less than the 1.83 average among patients on an oral drug.
The analysis also showed regional differences in the use of the two treatment options, with injections exceeding oral drug use in the North-Central U.S. region, while oral drugs were substantially more popular than injected drugs in the Western half of the United States. In other U.S. regions, the use of the two treatment routes was generally more balanced.
The study was sponsored by Otsuka, which markets the antipsychotic drug aripiprazole. Dr. Wong said he has been a consultant to Otsuka.
PHILADELPHIA – Long-acting, injectable formulations of antipsychotic drugs significantly boosted treatment compliance in patients with schizophrenia in a review of reimbursement records for more than 3,600 patients.
The increased compliance achieved with depot administration of antipsychotic medications makes it an attractive alternative to oral administration of antipsychotic drugs to patients with schizophrenia, Dr. Bruce J. Wong said at the meeting.
Greater use of depot medications could improve the management of patients with schizophrenia because treatment compliance is a major determinant of the ongoing health of schizophrenia patients, said Dr. Wong, a consultant clinical epidemiologist in Wayne, Pa.
"Lack of patient adherence to psychotropic medications is the single largest factor contributing to the ongoing morbidity of schizophrenia today. Even short gaps in antipsychotic usage increase the risk of rehospitalization" of patients, said Dr. Wong, also of the department of biostatistics and epidemiology at the University of Pennsylvania, Philadelphia.
"In practice today, depot, injected antipsychotic medications are secondary treatments, used almost like punishment when patients are noncompliant with oral drugs but should be viewed more like a reward," he said. The same drugs are formulated into oral and injectable preparations, so depot versions are not less effective or less safe than oral forms. Instead, a series of social factors relegate injectable formulations to second-line status: needle phobia in patients, a modest amount of pain that can occur when antipsychotic drugs are injected into muscle, the lack of comfort that psychiatrists often have with performing injections, and the need for a psychiatrist to obtain and have the drug on hand as opposed to the convenience of writing a prescription for the patient to get the oral form.
None of these alone is a major barrier, but together they seem to create enough of a roadblock to make injections less favored, Dr. Wong said in an interview.
To better document how the two delivery options relate to compliance, Dr. Wong and his associates used data collected on 3,004 commercially insured patients with schizophrenia in the MarketScan database of Thompson Reuters, and on 665 Medicare patients collected by the Center for Medicare and Medicaid Services during January 2005 to September 2010. The analysis focused on patients who began treatment with either an oral or a long-acting injected formulation of an antipsychotic drug, and who had at least 12 months of continuous health coverage prior to the index prescription.
In the commercial group, 13% of patients received an incident prescription for an injectable formulation, and 87% received an incident prescription for an oral antipsychotic. In the Medicare group, 22% filled a first-time prescription for a depot, injected formulation, and 78% fell into the oral group.
During follow-up, the researchers measured compliance by the average level of patients’ medication possession ratio. For patients taking an oral drug, this was determined by how many days during follow-up patients had their prescribed medication based on their history of filling their prescription. For patients receiving an injected drug, Dr. Wong and his associates calculated a medication possession ratio based on the frequency at which a patient’s records documented receiving an injection, and the number of days the injection covered during follow-up.
Among commercially insured patients, those who received injections had an average 67% medication possession ratio, compared with a 56% rate among patients taking an oral drug. In the Medicare group, injected patients had a 68% possession ratio, compared with 59% in those on an oral drug. In both subgroups the difference in ratios between the two types of treatment were statistically significant.
The analyses also identified other differences between the two treatment groups. Among the commercially insured, injected drugs were significantly more common than oral drugs in patients treated in comprehensive health plans, while injected drugs were used significantly less often than oral drugs in health maintenance organization settings.
Among commercially insured patients, those who received long-acting injections averaged 42 years old, significantly older than those who received oral drugs, who averaged 37 years old. Dr. Wong attributed this age difference to patients typically starting on an oral formulation and only switching to an injected formulation a few years later, once they showed that they were not reliable oral users. Medicare patients also showed a significant age difference, but the relationship flipped in this older age group. The mean age of the patients on injected antipsychotics was 67, while those on an oral drug averaged 73 years old. Dr. Wong said he did not have an explanation for this pattern among Medicare patients.
In the commercial group, patients on injected drugs were also significantly sicker, with an average Charlson comorbidity index of 0.58, compared with an average of 0.47 in the orally treated patients. Again, this pattern was reversed in Medicare patients, where the injected patients had an average Charlson comorbidity index score of 1.24, significantly less than the 1.83 average among patients on an oral drug.
The analysis also showed regional differences in the use of the two treatment options, with injections exceeding oral drug use in the North-Central U.S. region, while oral drugs were substantially more popular than injected drugs in the Western half of the United States. In other U.S. regions, the use of the two treatment routes was generally more balanced.
The study was sponsored by Otsuka, which markets the antipsychotic drug aripiprazole. Dr. Wong said he has been a consultant to Otsuka.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: Schizophrenia patients injected with a long-acting antipsychotic had 67%-68% compliance compared with 56%-59% compliance by patients on oral formulations.
Data Source: Data came from a review of reimbursement records for 3,669 patients with schizophrenia compiled in the MarketScan database by Thompson Reuters and for Medicare patients by the Center for Medicare and Medicaid Services.
Disclosures: The study was sponsored by Otsuka, which markets the antipsychotic drug aripiprazole. Dr. Wong said he has been a consultant to Otsuka.
Excited Delirium Syndrome Lacks Research, Coding
PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.
Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.
Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.
According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.
Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.
Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.
To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.
"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.
He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.
Medical treatment should be used as soon as possible to improve outcomes.
"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."
PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.
Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.
Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.
According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.
Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.
Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.
To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.
"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.
He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.
Medical treatment should be used as soon as possible to improve outcomes.
"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."
PHILADELPHIA – High doses of the anesthetic ketamine hydrochloride injected into the anterior thigh are the first line of defense when treating a patient with excited delirium syndrome, Dr. James R. Roberts reported at the meeting.
Excited delirium syndrome (ExDS) is characterized by delirium, agitation, acidosis, and hyper adrenergic autonomic dysfunction, according to the Journal of Emergency Medicine (J. Emerg. Med. 2011 March 24 [doi: 10.1016/j.jemermed.2011.02.017]). It is often comorbid with serious mental illness, drug abuse, or a combination of the two, said Dr. Roberts, who serves as director of emergency medicine at Mercy Philadelphia Hospital and Mercy Fitzgerald Hospital, and has more than 40 years of experience working in emergency departments.
Dr. Roberts said ExDS patients often have symptoms that include severe hypothermia, high levels of testosterone, elevated temperature, extreme paranoia, and tolerance to pain, and sweating. These patients also often display super-human strength and are non-compliant with police. Some ExDS patients have an attraction to glass or mirrors. After an episode, patients also tend to have no memory of the event.
According to the American College of Emergency Physicians (ACEP), which published a white paper on ExDS and formally recognized the illness as a unique syndrome in 2009, more than 95% of published fatal cases of ExDS involve males with a mean age of 36. After the cohort of people who abuse stimulants, those with psychiatric illness make up the second-largest and "distinctly smaller cohort of ExDS cases and deaths," according to the white paper.
Death from ExDS is often sudden and can result from several conditions, including cardiac arrest, renal failure, or hypothermia. The mortality is nearly 75%, yet ExDS is neither well recognized nor understood within the medical community, Dr. Roberts said. He also noted an absence of coding that can be used to classify the syndrome.
Diagnosis and research of ExDS is tricky, the report noted, because of a lack of well-defined and consistent case definitions, as well as shared characteristics with other diseases. For example, ExDS can be confused with heat stroke, alcohol withdrawal, and post-seizures.
To help decrease mortality and complications, Dr. Roberts encouraged physicians and law enforcement to raise their awareness of the condition.
"In the heat of the battle [between the patient and law enforcement], the patient stops struggling. The [police are] happy, but what really happens is the patient is dying and they’re not aware of it," Dr. Roberts said.
He added that police often mistake ExDS for another psychiatric disease, such as schizophrenia, and they often feel compelled to use physical force to encourage compliance. Tasers, he added, should only be used to remove any weapons the patient might have. Tasers increase the patient’s physiological stress and increase likelihood of death, he said.
Medical treatment should be used as soon as possible to improve outcomes.
"The cooler heads have to prevail," Dr. Roberts said. "Doctors have to set the example."
EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Metformin Resolves Amenorrhea in Antipsychotic-Treated Schizophrenia
PHILADELPHIA – Treatment with metformin led to striking resolution of amenorrhea in women with schizophrenia treated with an antipsychotic drug, in a randomized, controlled study with 84 patients.
Six months of treatment with a standard metformin dosage of 500 mg b.i.d. also led to significant weight loss, lower body mass index, and reduced insulin levels and insulin resistance. It also normalized levels of prolactin and luteinizing hormone, Dr. Ren-Rong Wu said at the annual meeting of the American Psychiatric Association.
Amenorrhea completely resolved in 28 (67%) of 42 women randomized to receive the metformin regimen after 3 months of treatment, compared with resolution in 2 (5%) of 42 women in the placebo arm, a statistically significant difference, reported Dr. Wu, a psychiatrist at the Mental Health Institute of the Second Xiangya Hospital of Central South University in Changsha, China.
"Metformin provides a new option for managing amenorrhea and weight gain" in women with schizophrenia on antipsychotic treatment, she said. The metformin regimen was safe, with an adverse-effect profile similar to that of the placebo arm.
Results from a prior study by Dr. Wu and her associates had documented the efficacy and safety of metformin for producing weight loss in patients with schizophrenia and antipsychotic-induced weight gain (JAMA 2008;299:185-93).
Based on the new results, "it’s reasonable to use metformin to treat women who develop amenorrhea on antipsychotic treatment," commented Dr. Keming Gao, a psychiatrist and clinical director of the mood disorders program at University Hospital Case Medical Center in Cleveland. Although Dr. Wu and her associates maintained their patients on metformin for only 6 months in the reported study, in routine practice it would be reasonable to keep women who safely respond to metformin on the drug for as long as they continue on an antipsychotic regimen, Dr. Gao said in an interview.
Menstrual irregularity is a common side effect of antipsychotic treatment in women, with reports documenting an incidence of 26%-78% (Br. J. Psychiatry 2003;182:199-204). The mechanism of this effect appears to be multifactorial, with antipsychotic drugs causing weight gain and insulin resistance that triggers hyperprolactinemia; the drugs also cause the pituitary to produce elevated levels of luteinizing hormone, Dr. Wu said. Insulin resistance also may have direct effects on ovarian function, she added.
Her study enrolled 84 women with first-episode schizophrenia who had developed amenorrhea while taking clozapine, olanzapine, risperidone, or sulpiride. Patients randomized to the metformin arm started treatment with 500 mg once daily, and if after 3 days they tolerated the drug, their dosage increased to 500 mg b.i.d. Resolution of amenorrhea was the study’s primary end point.
After 6 months on treatment, women in the metformin arm lost an average 2.4 kg of weight, had an average 0.9 kg/m2 reduction in their body mass index, had an average 8.8 microIU/mL drop in their blood insulin level, and had an average 2.0 point reduction in their insulin resistance index. All these changes were statistically significant, compared with baseline levels. In contrast, women in the placebo arm had, on average, significant increases from baseline in weight and body mass index, and had no significant change in their insulin or insulin resistance.
Metformin treatment also produced an average 84.9-mcg/L cut in prolactin levels and a 3.3-IU/L drop in luteinizing hormone levels, both statistically significant changes from baseline, as well as a significant reduction in the ratio of luteinizing hormone to follicle-stimulating hormone. None of these measures changed significantly in women who received placebo.
A series of regression analyses by Dr. Wu and her associates indicated that reduction in body weight was the strongest predictor of restoration of menstrual function in metformin-treated patients, followed by reduction in prolactin level. Normalization of luteinizing hormone and reduction of insulin resistance index also appeared to play significant, independent roles in resolving amenorrhea, she said.
Dr. Wu said that she had no disclosures.
PHILADELPHIA – Treatment with metformin led to striking resolution of amenorrhea in women with schizophrenia treated with an antipsychotic drug, in a randomized, controlled study with 84 patients.
Six months of treatment with a standard metformin dosage of 500 mg b.i.d. also led to significant weight loss, lower body mass index, and reduced insulin levels and insulin resistance. It also normalized levels of prolactin and luteinizing hormone, Dr. Ren-Rong Wu said at the annual meeting of the American Psychiatric Association.
Amenorrhea completely resolved in 28 (67%) of 42 women randomized to receive the metformin regimen after 3 months of treatment, compared with resolution in 2 (5%) of 42 women in the placebo arm, a statistically significant difference, reported Dr. Wu, a psychiatrist at the Mental Health Institute of the Second Xiangya Hospital of Central South University in Changsha, China.
"Metformin provides a new option for managing amenorrhea and weight gain" in women with schizophrenia on antipsychotic treatment, she said. The metformin regimen was safe, with an adverse-effect profile similar to that of the placebo arm.
Results from a prior study by Dr. Wu and her associates had documented the efficacy and safety of metformin for producing weight loss in patients with schizophrenia and antipsychotic-induced weight gain (JAMA 2008;299:185-93).
Based on the new results, "it’s reasonable to use metformin to treat women who develop amenorrhea on antipsychotic treatment," commented Dr. Keming Gao, a psychiatrist and clinical director of the mood disorders program at University Hospital Case Medical Center in Cleveland. Although Dr. Wu and her associates maintained their patients on metformin for only 6 months in the reported study, in routine practice it would be reasonable to keep women who safely respond to metformin on the drug for as long as they continue on an antipsychotic regimen, Dr. Gao said in an interview.
Menstrual irregularity is a common side effect of antipsychotic treatment in women, with reports documenting an incidence of 26%-78% (Br. J. Psychiatry 2003;182:199-204). The mechanism of this effect appears to be multifactorial, with antipsychotic drugs causing weight gain and insulin resistance that triggers hyperprolactinemia; the drugs also cause the pituitary to produce elevated levels of luteinizing hormone, Dr. Wu said. Insulin resistance also may have direct effects on ovarian function, she added.
Her study enrolled 84 women with first-episode schizophrenia who had developed amenorrhea while taking clozapine, olanzapine, risperidone, or sulpiride. Patients randomized to the metformin arm started treatment with 500 mg once daily, and if after 3 days they tolerated the drug, their dosage increased to 500 mg b.i.d. Resolution of amenorrhea was the study’s primary end point.
After 6 months on treatment, women in the metformin arm lost an average 2.4 kg of weight, had an average 0.9 kg/m2 reduction in their body mass index, had an average 8.8 microIU/mL drop in their blood insulin level, and had an average 2.0 point reduction in their insulin resistance index. All these changes were statistically significant, compared with baseline levels. In contrast, women in the placebo arm had, on average, significant increases from baseline in weight and body mass index, and had no significant change in their insulin or insulin resistance.
Metformin treatment also produced an average 84.9-mcg/L cut in prolactin levels and a 3.3-IU/L drop in luteinizing hormone levels, both statistically significant changes from baseline, as well as a significant reduction in the ratio of luteinizing hormone to follicle-stimulating hormone. None of these measures changed significantly in women who received placebo.
A series of regression analyses by Dr. Wu and her associates indicated that reduction in body weight was the strongest predictor of restoration of menstrual function in metformin-treated patients, followed by reduction in prolactin level. Normalization of luteinizing hormone and reduction of insulin resistance index also appeared to play significant, independent roles in resolving amenorrhea, she said.
Dr. Wu said that she had no disclosures.
PHILADELPHIA – Treatment with metformin led to striking resolution of amenorrhea in women with schizophrenia treated with an antipsychotic drug, in a randomized, controlled study with 84 patients.
Six months of treatment with a standard metformin dosage of 500 mg b.i.d. also led to significant weight loss, lower body mass index, and reduced insulin levels and insulin resistance. It also normalized levels of prolactin and luteinizing hormone, Dr. Ren-Rong Wu said at the annual meeting of the American Psychiatric Association.
Amenorrhea completely resolved in 28 (67%) of 42 women randomized to receive the metformin regimen after 3 months of treatment, compared with resolution in 2 (5%) of 42 women in the placebo arm, a statistically significant difference, reported Dr. Wu, a psychiatrist at the Mental Health Institute of the Second Xiangya Hospital of Central South University in Changsha, China.
"Metformin provides a new option for managing amenorrhea and weight gain" in women with schizophrenia on antipsychotic treatment, she said. The metformin regimen was safe, with an adverse-effect profile similar to that of the placebo arm.
Results from a prior study by Dr. Wu and her associates had documented the efficacy and safety of metformin for producing weight loss in patients with schizophrenia and antipsychotic-induced weight gain (JAMA 2008;299:185-93).
Based on the new results, "it’s reasonable to use metformin to treat women who develop amenorrhea on antipsychotic treatment," commented Dr. Keming Gao, a psychiatrist and clinical director of the mood disorders program at University Hospital Case Medical Center in Cleveland. Although Dr. Wu and her associates maintained their patients on metformin for only 6 months in the reported study, in routine practice it would be reasonable to keep women who safely respond to metformin on the drug for as long as they continue on an antipsychotic regimen, Dr. Gao said in an interview.
Menstrual irregularity is a common side effect of antipsychotic treatment in women, with reports documenting an incidence of 26%-78% (Br. J. Psychiatry 2003;182:199-204). The mechanism of this effect appears to be multifactorial, with antipsychotic drugs causing weight gain and insulin resistance that triggers hyperprolactinemia; the drugs also cause the pituitary to produce elevated levels of luteinizing hormone, Dr. Wu said. Insulin resistance also may have direct effects on ovarian function, she added.
Her study enrolled 84 women with first-episode schizophrenia who had developed amenorrhea while taking clozapine, olanzapine, risperidone, or sulpiride. Patients randomized to the metformin arm started treatment with 500 mg once daily, and if after 3 days they tolerated the drug, their dosage increased to 500 mg b.i.d. Resolution of amenorrhea was the study’s primary end point.
After 6 months on treatment, women in the metformin arm lost an average 2.4 kg of weight, had an average 0.9 kg/m2 reduction in their body mass index, had an average 8.8 microIU/mL drop in their blood insulin level, and had an average 2.0 point reduction in their insulin resistance index. All these changes were statistically significant, compared with baseline levels. In contrast, women in the placebo arm had, on average, significant increases from baseline in weight and body mass index, and had no significant change in their insulin or insulin resistance.
Metformin treatment also produced an average 84.9-mcg/L cut in prolactin levels and a 3.3-IU/L drop in luteinizing hormone levels, both statistically significant changes from baseline, as well as a significant reduction in the ratio of luteinizing hormone to follicle-stimulating hormone. None of these measures changed significantly in women who received placebo.
A series of regression analyses by Dr. Wu and her associates indicated that reduction in body weight was the strongest predictor of restoration of menstrual function in metformin-treated patients, followed by reduction in prolactin level. Normalization of luteinizing hormone and reduction of insulin resistance index also appeared to play significant, independent roles in resolving amenorrhea, she said.
Dr. Wu said that she had no disclosures.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: Metformin treatment resolved amenorrhea in 67% of women with schizophrenia on an antipsychotic, compared with 5% resolution in the placebo arm.
Data Source: Data came from a randomized, controlled study with 84 patients at a single center in China.
Disclosures: Dr. Wu said she had no disclosures.
Short Psychiatric Hospitalizations Linked to Higher Readmissions
PHILADELPHIA – Putting a uniform, brief cap on the number of days that psychiatric patients can remain hospitalized might have the unintended consequence of significantly boosting the rate of short-term hospital readmissions, according to results from a study of more than 12,000 patients at one U.S. hospital.
Psychiatric patients hospitalized for 4 days or fewer had a statistically significant 25% increased rate of readmission in the following 30 days in an analysis that adjusted for many possible demographic and clinical confounders, Dr. John W. Goethe said at the annual meeting of the American Psychiatric Association.
At a time when the Centers for Medicare and Medicaid Services (CMS) is poised to start penalizing hospitals with outlier short-term readmission rates, the finding highlights the complex constellation of factors that affect 30-day readmission rates. The finding also underscores the potent, rock-and-hard-place one-two punch that hospitals and clinicians will soon face when treating psychiatric patients: The pressure from payers to quickly move inpatients out the door and the penalty that CMS will levy if these patients wind up rehospitalized less than a month later.
"Readmission is a complex problem and an extremely crude proxy for the many things that can make a patient’s condition deteriorate," said Dr. Goethe, a psychiatrist and director of the center for research and education at Hartford (Conn.) Hospital.
"Readmission rates are clearly related to length of stay," and trying to assess quality of hospital care with the metric of readmission loses sight of factors contributing to readmissions that can be out of a hospital’s control, he said in an interview.
A length-of-stay cap fixed at something like 4 days "does not take into account a patient’s particular circumstances" and might mandate a hospitalization duration that is "inadequate to address what brought the patient into the hospital," he said. The important role that length of stay plays in readmissions should be "taken into account by policy makers who are planning financial penalties for hospitals with what [they consider] inappropriate readmission rates," Dr. Goethe said.
His study included 12,830 patients with a psychiatric diagnosis who were admitted to Hartford Hospital during January 2002-May 2008. The majority of patients, 71%, were 18-60 years old; 14% were age 17 or younger and 15% were age 61 or older. Patient records showed a length of stay of 4 days or fewer for 13% of pediatric patients, 33% of adults, and 9% of older patients. The rate of readmission within 30 days was 7% for pediatric patients, 10% for adults, and 9% among older patients.
The researchers then performed a series of proportional-hazard regression analyses that calculated the relationship between a 4-day-or-less length of stay and readmission rates. They adjusted for many baseline factors, including age, sex, race and ethnicity, type of psychiatric diagnosis, types of treatment received, and prior hospitalization history. The result showed that patients hospitalized for 5 days or more had a statistically significant 20% reduced rate of 30-day hospital readmission, compared with patients hospitalized for 4 days or fewer. Expressed conversely, patients hospitalized for 4 days or fewer had a 25% higher rate of 30-day readmission than those hospitalized for longer periods.
The analyses identified six other variables that also had a significant, independent effect on 30-day readmission rate: female sex, schizophrenia, and attention-deficit disorder linked with a reduced readmission rate, while benzodiazepine treatment, dementia, and conduct disorder all linked with an increased rate.
Results from a companion study identified other factors that significantly linked with 30-day readmission. Patients who previously had been hospitalized within 30 days, 90 days, or 2 years of the index hospitalization all faced a significantly increased risk for 30-day rehospitalization following the index admission. And patients treated with six or more psychotropic drugs had a significantly increased risk for 30-day readmission, compared with patients who received five or fewer psychotropic drugs.
"To our knowledge, this is the largest patient sample used to address this question" for psychiatric patients, Dr. Goethe said. He cautioned that the analysis did not take into account several other factors that could also affect readmission rates, such as severity of illness, socioeconomic status, social support, quality of life, and adherence to treatment.
Dr. Goethe said he had no disclosures, but his hospital’s research program has received grants from several drug companies.
PHILADELPHIA – Putting a uniform, brief cap on the number of days that psychiatric patients can remain hospitalized might have the unintended consequence of significantly boosting the rate of short-term hospital readmissions, according to results from a study of more than 12,000 patients at one U.S. hospital.
Psychiatric patients hospitalized for 4 days or fewer had a statistically significant 25% increased rate of readmission in the following 30 days in an analysis that adjusted for many possible demographic and clinical confounders, Dr. John W. Goethe said at the annual meeting of the American Psychiatric Association.
At a time when the Centers for Medicare and Medicaid Services (CMS) is poised to start penalizing hospitals with outlier short-term readmission rates, the finding highlights the complex constellation of factors that affect 30-day readmission rates. The finding also underscores the potent, rock-and-hard-place one-two punch that hospitals and clinicians will soon face when treating psychiatric patients: The pressure from payers to quickly move inpatients out the door and the penalty that CMS will levy if these patients wind up rehospitalized less than a month later.
"Readmission is a complex problem and an extremely crude proxy for the many things that can make a patient’s condition deteriorate," said Dr. Goethe, a psychiatrist and director of the center for research and education at Hartford (Conn.) Hospital.
"Readmission rates are clearly related to length of stay," and trying to assess quality of hospital care with the metric of readmission loses sight of factors contributing to readmissions that can be out of a hospital’s control, he said in an interview.
A length-of-stay cap fixed at something like 4 days "does not take into account a patient’s particular circumstances" and might mandate a hospitalization duration that is "inadequate to address what brought the patient into the hospital," he said. The important role that length of stay plays in readmissions should be "taken into account by policy makers who are planning financial penalties for hospitals with what [they consider] inappropriate readmission rates," Dr. Goethe said.
His study included 12,830 patients with a psychiatric diagnosis who were admitted to Hartford Hospital during January 2002-May 2008. The majority of patients, 71%, were 18-60 years old; 14% were age 17 or younger and 15% were age 61 or older. Patient records showed a length of stay of 4 days or fewer for 13% of pediatric patients, 33% of adults, and 9% of older patients. The rate of readmission within 30 days was 7% for pediatric patients, 10% for adults, and 9% among older patients.
The researchers then performed a series of proportional-hazard regression analyses that calculated the relationship between a 4-day-or-less length of stay and readmission rates. They adjusted for many baseline factors, including age, sex, race and ethnicity, type of psychiatric diagnosis, types of treatment received, and prior hospitalization history. The result showed that patients hospitalized for 5 days or more had a statistically significant 20% reduced rate of 30-day hospital readmission, compared with patients hospitalized for 4 days or fewer. Expressed conversely, patients hospitalized for 4 days or fewer had a 25% higher rate of 30-day readmission than those hospitalized for longer periods.
The analyses identified six other variables that also had a significant, independent effect on 30-day readmission rate: female sex, schizophrenia, and attention-deficit disorder linked with a reduced readmission rate, while benzodiazepine treatment, dementia, and conduct disorder all linked with an increased rate.
Results from a companion study identified other factors that significantly linked with 30-day readmission. Patients who previously had been hospitalized within 30 days, 90 days, or 2 years of the index hospitalization all faced a significantly increased risk for 30-day rehospitalization following the index admission. And patients treated with six or more psychotropic drugs had a significantly increased risk for 30-day readmission, compared with patients who received five or fewer psychotropic drugs.
"To our knowledge, this is the largest patient sample used to address this question" for psychiatric patients, Dr. Goethe said. He cautioned that the analysis did not take into account several other factors that could also affect readmission rates, such as severity of illness, socioeconomic status, social support, quality of life, and adherence to treatment.
Dr. Goethe said he had no disclosures, but his hospital’s research program has received grants from several drug companies.
PHILADELPHIA – Putting a uniform, brief cap on the number of days that psychiatric patients can remain hospitalized might have the unintended consequence of significantly boosting the rate of short-term hospital readmissions, according to results from a study of more than 12,000 patients at one U.S. hospital.
Psychiatric patients hospitalized for 4 days or fewer had a statistically significant 25% increased rate of readmission in the following 30 days in an analysis that adjusted for many possible demographic and clinical confounders, Dr. John W. Goethe said at the annual meeting of the American Psychiatric Association.
At a time when the Centers for Medicare and Medicaid Services (CMS) is poised to start penalizing hospitals with outlier short-term readmission rates, the finding highlights the complex constellation of factors that affect 30-day readmission rates. The finding also underscores the potent, rock-and-hard-place one-two punch that hospitals and clinicians will soon face when treating psychiatric patients: The pressure from payers to quickly move inpatients out the door and the penalty that CMS will levy if these patients wind up rehospitalized less than a month later.
"Readmission is a complex problem and an extremely crude proxy for the many things that can make a patient’s condition deteriorate," said Dr. Goethe, a psychiatrist and director of the center for research and education at Hartford (Conn.) Hospital.
"Readmission rates are clearly related to length of stay," and trying to assess quality of hospital care with the metric of readmission loses sight of factors contributing to readmissions that can be out of a hospital’s control, he said in an interview.
A length-of-stay cap fixed at something like 4 days "does not take into account a patient’s particular circumstances" and might mandate a hospitalization duration that is "inadequate to address what brought the patient into the hospital," he said. The important role that length of stay plays in readmissions should be "taken into account by policy makers who are planning financial penalties for hospitals with what [they consider] inappropriate readmission rates," Dr. Goethe said.
His study included 12,830 patients with a psychiatric diagnosis who were admitted to Hartford Hospital during January 2002-May 2008. The majority of patients, 71%, were 18-60 years old; 14% were age 17 or younger and 15% were age 61 or older. Patient records showed a length of stay of 4 days or fewer for 13% of pediatric patients, 33% of adults, and 9% of older patients. The rate of readmission within 30 days was 7% for pediatric patients, 10% for adults, and 9% among older patients.
The researchers then performed a series of proportional-hazard regression analyses that calculated the relationship between a 4-day-or-less length of stay and readmission rates. They adjusted for many baseline factors, including age, sex, race and ethnicity, type of psychiatric diagnosis, types of treatment received, and prior hospitalization history. The result showed that patients hospitalized for 5 days or more had a statistically significant 20% reduced rate of 30-day hospital readmission, compared with patients hospitalized for 4 days or fewer. Expressed conversely, patients hospitalized for 4 days or fewer had a 25% higher rate of 30-day readmission than those hospitalized for longer periods.
The analyses identified six other variables that also had a significant, independent effect on 30-day readmission rate: female sex, schizophrenia, and attention-deficit disorder linked with a reduced readmission rate, while benzodiazepine treatment, dementia, and conduct disorder all linked with an increased rate.
Results from a companion study identified other factors that significantly linked with 30-day readmission. Patients who previously had been hospitalized within 30 days, 90 days, or 2 years of the index hospitalization all faced a significantly increased risk for 30-day rehospitalization following the index admission. And patients treated with six or more psychotropic drugs had a significantly increased risk for 30-day readmission, compared with patients who received five or fewer psychotropic drugs.
"To our knowledge, this is the largest patient sample used to address this question" for psychiatric patients, Dr. Goethe said. He cautioned that the analysis did not take into account several other factors that could also affect readmission rates, such as severity of illness, socioeconomic status, social support, quality of life, and adherence to treatment.
Dr. Goethe said he had no disclosures, but his hospital’s research program has received grants from several drug companies.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION
Major Finding: Psychiatric patients hospitalized for 5 or more days had a 20% reduced 30-day rehospitalization rate, compared with shorter hospitalizations.
Data Source: Data came from an analysis of 12,830 psychiatric patients hospitalized at one U.S. center during 2002-2008.
Disclosures: Dr. Goethe said he had no disclosures, but his hospital’s research program has received grants from several drug companies.
APA President-Elect Stresses Unity
PHILADELPHIA – Dr. Dilip V. Jeste fell in love with psychiatry while growing up in a remote village in India. "Becoming an APA member seemed like a dream," Dr. Jeste told a packed hotel ballroom May 6 during the opening session of the annual meeting of the American Psychiatric Association.
Today, Dr. Jeste is not only a member of the American Psychiatric Association but the group’s president-elect. He said the focus of his 1-year term will be on unity.
"The APA is a big tent," said Dr. Jeste, the Estelle and Edgar Levi Chair in Aging at the University of California, San Diego. He wants to make the organization broader, more international, and younger. "We need a concerted effort to [increase] diversity at all levels."
The APA exists to fight mental illness and to make sure that patients get the best possible care, he said.
"We can’t do this by ourselves," said Dr. Jeste, emphasizing the need to coordinate with other organizations, such as the American Medical Association and the National Alliance on Mental Illness.
He also stressed the importance of focusing on enhancing resilience and promoting wellness across the lifespan. "Older people are not a drain on society, but a resource," said Dr. Jeste, pointing out that the number of people in the United States aged 65 years and older is expected to double by 2030.
Dr. Jeste also serves as distinguished professor of psychiatry and neurosciences and the director of the Sam and Rose Stein Institute for Research on Aging at the university, and as editor-in-chief of the American Journal of Geriatric Psychiatry.
Earlier in the session, Dr. John M. Oldham, the current APA president, said that the workforce issues facing psychiatry are a huge concern. The latest figures from the National Resident Matching Program showed that fewer medical students chose psychiatry for the sixth year in a row. Yet, the shortage of psychiatrists continues in the United States and internationally.
"Medical students say the road to happiness" can be found in four specialties – anesthesiology, dermatology, ophthalmology, and radiology – but "students who want to go into psychiatry want to connect with patients," said Dr. Oldham, chief of staff at the Menninger Clinic, Houston.
The theme of his term – integrated care – stresses the need for psychiatry to be part of all health care discussions. "As medical homes come online, psychiatry must be at the table," he said.
PHILADELPHIA – Dr. Dilip V. Jeste fell in love with psychiatry while growing up in a remote village in India. "Becoming an APA member seemed like a dream," Dr. Jeste told a packed hotel ballroom May 6 during the opening session of the annual meeting of the American Psychiatric Association.
Today, Dr. Jeste is not only a member of the American Psychiatric Association but the group’s president-elect. He said the focus of his 1-year term will be on unity.
"The APA is a big tent," said Dr. Jeste, the Estelle and Edgar Levi Chair in Aging at the University of California, San Diego. He wants to make the organization broader, more international, and younger. "We need a concerted effort to [increase] diversity at all levels."
The APA exists to fight mental illness and to make sure that patients get the best possible care, he said.
"We can’t do this by ourselves," said Dr. Jeste, emphasizing the need to coordinate with other organizations, such as the American Medical Association and the National Alliance on Mental Illness.
He also stressed the importance of focusing on enhancing resilience and promoting wellness across the lifespan. "Older people are not a drain on society, but a resource," said Dr. Jeste, pointing out that the number of people in the United States aged 65 years and older is expected to double by 2030.
Dr. Jeste also serves as distinguished professor of psychiatry and neurosciences and the director of the Sam and Rose Stein Institute for Research on Aging at the university, and as editor-in-chief of the American Journal of Geriatric Psychiatry.
Earlier in the session, Dr. John M. Oldham, the current APA president, said that the workforce issues facing psychiatry are a huge concern. The latest figures from the National Resident Matching Program showed that fewer medical students chose psychiatry for the sixth year in a row. Yet, the shortage of psychiatrists continues in the United States and internationally.
"Medical students say the road to happiness" can be found in four specialties – anesthesiology, dermatology, ophthalmology, and radiology – but "students who want to go into psychiatry want to connect with patients," said Dr. Oldham, chief of staff at the Menninger Clinic, Houston.
The theme of his term – integrated care – stresses the need for psychiatry to be part of all health care discussions. "As medical homes come online, psychiatry must be at the table," he said.
PHILADELPHIA – Dr. Dilip V. Jeste fell in love with psychiatry while growing up in a remote village in India. "Becoming an APA member seemed like a dream," Dr. Jeste told a packed hotel ballroom May 6 during the opening session of the annual meeting of the American Psychiatric Association.
Today, Dr. Jeste is not only a member of the American Psychiatric Association but the group’s president-elect. He said the focus of his 1-year term will be on unity.
"The APA is a big tent," said Dr. Jeste, the Estelle and Edgar Levi Chair in Aging at the University of California, San Diego. He wants to make the organization broader, more international, and younger. "We need a concerted effort to [increase] diversity at all levels."
The APA exists to fight mental illness and to make sure that patients get the best possible care, he said.
"We can’t do this by ourselves," said Dr. Jeste, emphasizing the need to coordinate with other organizations, such as the American Medical Association and the National Alliance on Mental Illness.
He also stressed the importance of focusing on enhancing resilience and promoting wellness across the lifespan. "Older people are not a drain on society, but a resource," said Dr. Jeste, pointing out that the number of people in the United States aged 65 years and older is expected to double by 2030.
Dr. Jeste also serves as distinguished professor of psychiatry and neurosciences and the director of the Sam and Rose Stein Institute for Research on Aging at the university, and as editor-in-chief of the American Journal of Geriatric Psychiatry.
Earlier in the session, Dr. John M. Oldham, the current APA president, said that the workforce issues facing psychiatry are a huge concern. The latest figures from the National Resident Matching Program showed that fewer medical students chose psychiatry for the sixth year in a row. Yet, the shortage of psychiatrists continues in the United States and internationally.
"Medical students say the road to happiness" can be found in four specialties – anesthesiology, dermatology, ophthalmology, and radiology – but "students who want to go into psychiatry want to connect with patients," said Dr. Oldham, chief of staff at the Menninger Clinic, Houston.
The theme of his term – integrated care – stresses the need for psychiatry to be part of all health care discussions. "As medical homes come online, psychiatry must be at the table," he said.
FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION