APA 2013

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – New drugs aimed at treating the nonpsychotic symptoms of schizophrenia that impair patients’ daily functioning are likely to move into the clinic soon, predicts Dr. Stephen R. Marder, professor and director of the section on psychosis at the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

Antipsychotics have been available since the early 1950s, but functional impairments for people with schizophrenia continue to persist, he said. In fact, fewer than 20% are able to work independently, he said at the annual meeting of the American Psychiatric Association. Until recently, "clinical practice was focused on what drugs were able to do, which was to dampen the psychotic symptoms of schizophrenia, and drug development was at a halt," said Dr. Marder, who also serves as director of the Mental Illness Research, Education, and Clinical Center, Los Angeles.

But that has changed, thanks to MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia), a collaborative effort of about 300 investigators focused on facilitating drug development for nonpsychotic symptoms.

"If the goal is to be able to improve the functioning in schizophrenia – for people to be able to work, live independently, participate in family and social life – there are some attractive targets: basic cognition, negative symptoms, and social cognition," Dr. Marder explained.

Roughly a half-dozen agents targeting these symptoms are now in phase II or III clinical trials. "We are at a stage where ... it’s conceivable that in late 2014 or 2015, we will actually have a drug for negative symptoms, with other drugs for cognition following shortly thereafter," he said "So it’s a time of optimism."

A relatively new area of research focus in schizophrenia is impairment of social cognition and the ability to read other people based on cues such as body language, facial expressions, and tone of voice.

Emerging data suggest that the naturally occurring hormone and neurotransmitter oxytocin, long used in obstetrics, is beneficial in this context.

"It is involved in multiple aspects of social behavior and related emotions," Dr. Marder noted. Administration to mentally healthy individuals has been associated with increased trust when playing games and increased sensitivity to social signals.

In a phase II trial, patients with schizophrenia had better uptake of social cognition training when given intranasal oxytocin, as compared with placebo, shortly before training began.

Relative to placebo, oxytocin did not improve low-level function, such as ability to interpret facial expressions. However, it did improve high-level function, such as the ability to detect sarcasm, assessed in the study with a test of empathic accuracy. Moreover, the effect was sustained, lasting at least a month.

Thus, an old drug might eventually find new use to treat a complex symptom of schizophrenia, he said.

"We are feeling relatively optimistic that these efforts are going to lead, in the relatively near future, to better treatment," Dr. Marder said.

Dr. Marder disclosed that he is on the advisory boards of numerous pharmaceutical companies, including Abbott, Amgen, Roche, Shire, Otsuka, Wyeth, Pfizer, and Lundbeck, and that he receives research support from Novartis, GlaxoSmithKline, Sunovion, and PsychoGenics.

SAN FRANCISCO – New drugs aimed at treating the nonpsychotic symptoms of schizophrenia that impair patients’ daily functioning are likely to move into the clinic soon, predicts Dr. Stephen R. Marder, professor and director of the section on psychosis at the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

Antipsychotics have been available since the early 1950s, but functional impairments for people with schizophrenia continue to persist, he said. In fact, fewer than 20% are able to work independently, he said at the annual meeting of the American Psychiatric Association. Until recently, "clinical practice was focused on what drugs were able to do, which was to dampen the psychotic symptoms of schizophrenia, and drug development was at a halt," said Dr. Marder, who also serves as director of the Mental Illness Research, Education, and Clinical Center, Los Angeles.

But that has changed, thanks to MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia), a collaborative effort of about 300 investigators focused on facilitating drug development for nonpsychotic symptoms.

"If the goal is to be able to improve the functioning in schizophrenia – for people to be able to work, live independently, participate in family and social life – there are some attractive targets: basic cognition, negative symptoms, and social cognition," Dr. Marder explained.

Roughly a half-dozen agents targeting these symptoms are now in phase II or III clinical trials. "We are at a stage where ... it’s conceivable that in late 2014 or 2015, we will actually have a drug for negative symptoms, with other drugs for cognition following shortly thereafter," he said "So it’s a time of optimism."

A relatively new area of research focus in schizophrenia is impairment of social cognition and the ability to read other people based on cues such as body language, facial expressions, and tone of voice.

Emerging data suggest that the naturally occurring hormone and neurotransmitter oxytocin, long used in obstetrics, is beneficial in this context.

"It is involved in multiple aspects of social behavior and related emotions," Dr. Marder noted. Administration to mentally healthy individuals has been associated with increased trust when playing games and increased sensitivity to social signals.

In a phase II trial, patients with schizophrenia had better uptake of social cognition training when given intranasal oxytocin, as compared with placebo, shortly before training began.

Relative to placebo, oxytocin did not improve low-level function, such as ability to interpret facial expressions. However, it did improve high-level function, such as the ability to detect sarcasm, assessed in the study with a test of empathic accuracy. Moreover, the effect was sustained, lasting at least a month.

Thus, an old drug might eventually find new use to treat a complex symptom of schizophrenia, he said.

"We are feeling relatively optimistic that these efforts are going to lead, in the relatively near future, to better treatment," Dr. Marder said.

Dr. Marder disclosed that he is on the advisory boards of numerous pharmaceutical companies, including Abbott, Amgen, Roche, Shire, Otsuka, Wyeth, Pfizer, and Lundbeck, and that he receives research support from Novartis, GlaxoSmithKline, Sunovion, and PsychoGenics.

SAN FRANCISCO – New drugs aimed at treating the nonpsychotic symptoms of schizophrenia that impair patients’ daily functioning are likely to move into the clinic soon, predicts Dr. Stephen R. Marder, professor and director of the section on psychosis at the Semel Institute for Neuroscience and Human Behavior at the University of California, Los Angeles.

Antipsychotics have been available since the early 1950s, but functional impairments for people with schizophrenia continue to persist, he said. In fact, fewer than 20% are able to work independently, he said at the annual meeting of the American Psychiatric Association. Until recently, "clinical practice was focused on what drugs were able to do, which was to dampen the psychotic symptoms of schizophrenia, and drug development was at a halt," said Dr. Marder, who also serves as director of the Mental Illness Research, Education, and Clinical Center, Los Angeles.

But that has changed, thanks to MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia), a collaborative effort of about 300 investigators focused on facilitating drug development for nonpsychotic symptoms.

"If the goal is to be able to improve the functioning in schizophrenia – for people to be able to work, live independently, participate in family and social life – there are some attractive targets: basic cognition, negative symptoms, and social cognition," Dr. Marder explained.

Roughly a half-dozen agents targeting these symptoms are now in phase II or III clinical trials. "We are at a stage where ... it’s conceivable that in late 2014 or 2015, we will actually have a drug for negative symptoms, with other drugs for cognition following shortly thereafter," he said "So it’s a time of optimism."

A relatively new area of research focus in schizophrenia is impairment of social cognition and the ability to read other people based on cues such as body language, facial expressions, and tone of voice.

Emerging data suggest that the naturally occurring hormone and neurotransmitter oxytocin, long used in obstetrics, is beneficial in this context.

"It is involved in multiple aspects of social behavior and related emotions," Dr. Marder noted. Administration to mentally healthy individuals has been associated with increased trust when playing games and increased sensitivity to social signals.

In a phase II trial, patients with schizophrenia had better uptake of social cognition training when given intranasal oxytocin, as compared with placebo, shortly before training began.

Relative to placebo, oxytocin did not improve low-level function, such as ability to interpret facial expressions. However, it did improve high-level function, such as the ability to detect sarcasm, assessed in the study with a test of empathic accuracy. Moreover, the effect was sustained, lasting at least a month.

Thus, an old drug might eventually find new use to treat a complex symptom of schizophrenia, he said.

"We are feeling relatively optimistic that these efforts are going to lead, in the relatively near future, to better treatment," Dr. Marder said.

Dr. Marder disclosed that he is on the advisory boards of numerous pharmaceutical companies, including Abbott, Amgen, Roche, Shire, Otsuka, Wyeth, Pfizer, and Lundbeck, and that he receives research support from Novartis, GlaxoSmithKline, Sunovion, and PsychoGenics.

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

[email protected]

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

[email protected]

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

[email protected]

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – Suicide attempts that required treatment were more than three times as likely in teenagers who reported being bullied online, compared with youths who were not bullied, an analysis of federal data on more than 15,000 adolescents found.

Girls faced twice as much electronic bullying as boys. Cyberbullying was reported by 22% of girls and 11% of boys, according to the study of data on teens aged 13-18 years from the Centers for Disease Control and Prevention’s 2011 Youth Risk Behavior Survey, the first of its kind to ask questions about cyberbullying.

Other data suggest that 80% of U.S. teens use social networking sites, Dr. Kristi M. Kindrick said at a press briefing at the annual meeting of the American Psychiatric Association.

Among 13- to 17-year-olds, an estimated 12% have suicidal ideation, 4% plan suicide, and another 4% attempt suicide, rates that now are similar to those in adults, she noted.

The effects of online harassment on suicidal risk may be one reason that suicide is now the third leading cause of death in adolescents, behind accidents and homicides.

Dr. Kindrick and her associates found that one in six teens reported being electronically bullied, compared with one in five who said they had been bullied on school grounds. Almost 6% of high school students said they had missed school because of fears for their safety. The rate of conventional off-line bullying, such as harassment in the schoolyard, was 22% for girls (the same rate as online bullying) and 18% for boys (higher than the 11% rate for cyberbullying), reported Dr. Kindrick, a fourth-year resident in psychiatry at the University of Arkansas for Medical Sciences, Little Rock, who was moved to do the study after a young patient killed herself following cyberbullying.

Offline bullying, however, only doubled the risk for suicide, compared with the tripling in risk seen with cyberbullying, she said. Rates for the most serious cases – suicide attempts that required treatment – were 1.5% for youths who had not been bullied, 2.3% for those who reported being bullied at school, 5.4% among those who had been cyberbullied, and 6% if they had been bullied both offline and online.

Dr. Kindrick said that she is a clinician more than a researcher, and her goal is to educate communities and schools about this problem. Clinicians need to ask about bullying, sometimes in more than one way, to identify youths who are being bullied and help them cope and get help.

"Why I really care about it is because I’m a mom. I have three young children," she added.

The fact that rates of suicidal ideation, suicide planning, and suicide attempts in teens now are nearly the same as in adults belies the notion that today’s children and adolescents live carefree lives. The highest rates of cyberbullying in the study targeted white girls, she said, so "the movie ‘Mean Girls’ kind of lives up to its reputation here."

Dr. Kindrick reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Suicide attempts that required treatment were more than three times as likely in teenagers who reported being bullied online, compared with youths who were not bullied, an analysis of federal data on more than 15,000 adolescents found.

Girls faced twice as much electronic bullying as boys. Cyberbullying was reported by 22% of girls and 11% of boys, according to the study of data on teens aged 13-18 years from the Centers for Disease Control and Prevention’s 2011 Youth Risk Behavior Survey, the first of its kind to ask questions about cyberbullying.

Other data suggest that 80% of U.S. teens use social networking sites, Dr. Kristi M. Kindrick said at a press briefing at the annual meeting of the American Psychiatric Association.

Among 13- to 17-year-olds, an estimated 12% have suicidal ideation, 4% plan suicide, and another 4% attempt suicide, rates that now are similar to those in adults, she noted.

The effects of online harassment on suicidal risk may be one reason that suicide is now the third leading cause of death in adolescents, behind accidents and homicides.

Dr. Kindrick and her associates found that one in six teens reported being electronically bullied, compared with one in five who said they had been bullied on school grounds. Almost 6% of high school students said they had missed school because of fears for their safety. The rate of conventional off-line bullying, such as harassment in the schoolyard, was 22% for girls (the same rate as online bullying) and 18% for boys (higher than the 11% rate for cyberbullying), reported Dr. Kindrick, a fourth-year resident in psychiatry at the University of Arkansas for Medical Sciences, Little Rock, who was moved to do the study after a young patient killed herself following cyberbullying.

Offline bullying, however, only doubled the risk for suicide, compared with the tripling in risk seen with cyberbullying, she said. Rates for the most serious cases – suicide attempts that required treatment – were 1.5% for youths who had not been bullied, 2.3% for those who reported being bullied at school, 5.4% among those who had been cyberbullied, and 6% if they had been bullied both offline and online.

Dr. Kindrick said that she is a clinician more than a researcher, and her goal is to educate communities and schools about this problem. Clinicians need to ask about bullying, sometimes in more than one way, to identify youths who are being bullied and help them cope and get help.

"Why I really care about it is because I’m a mom. I have three young children," she added.

The fact that rates of suicidal ideation, suicide planning, and suicide attempts in teens now are nearly the same as in adults belies the notion that today’s children and adolescents live carefree lives. The highest rates of cyberbullying in the study targeted white girls, she said, so "the movie ‘Mean Girls’ kind of lives up to its reputation here."

Dr. Kindrick reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Suicide attempts that required treatment were more than three times as likely in teenagers who reported being bullied online, compared with youths who were not bullied, an analysis of federal data on more than 15,000 adolescents found.

Girls faced twice as much electronic bullying as boys. Cyberbullying was reported by 22% of girls and 11% of boys, according to the study of data on teens aged 13-18 years from the Centers for Disease Control and Prevention’s 2011 Youth Risk Behavior Survey, the first of its kind to ask questions about cyberbullying.

Other data suggest that 80% of U.S. teens use social networking sites, Dr. Kristi M. Kindrick said at a press briefing at the annual meeting of the American Psychiatric Association.

Among 13- to 17-year-olds, an estimated 12% have suicidal ideation, 4% plan suicide, and another 4% attempt suicide, rates that now are similar to those in adults, she noted.

The effects of online harassment on suicidal risk may be one reason that suicide is now the third leading cause of death in adolescents, behind accidents and homicides.

Dr. Kindrick and her associates found that one in six teens reported being electronically bullied, compared with one in five who said they had been bullied on school grounds. Almost 6% of high school students said they had missed school because of fears for their safety. The rate of conventional off-line bullying, such as harassment in the schoolyard, was 22% for girls (the same rate as online bullying) and 18% for boys (higher than the 11% rate for cyberbullying), reported Dr. Kindrick, a fourth-year resident in psychiatry at the University of Arkansas for Medical Sciences, Little Rock, who was moved to do the study after a young patient killed herself following cyberbullying.

Offline bullying, however, only doubled the risk for suicide, compared with the tripling in risk seen with cyberbullying, she said. Rates for the most serious cases – suicide attempts that required treatment – were 1.5% for youths who had not been bullied, 2.3% for those who reported being bullied at school, 5.4% among those who had been cyberbullied, and 6% if they had been bullied both offline and online.

Dr. Kindrick said that she is a clinician more than a researcher, and her goal is to educate communities and schools about this problem. Clinicians need to ask about bullying, sometimes in more than one way, to identify youths who are being bullied and help them cope and get help.

"Why I really care about it is because I’m a mom. I have three young children," she added.

The fact that rates of suicidal ideation, suicide planning, and suicide attempts in teens now are nearly the same as in adults belies the notion that today’s children and adolescents live carefree lives. The highest rates of cyberbullying in the study targeted white girls, she said, so "the movie ‘Mean Girls’ kind of lives up to its reputation here."

Dr. Kindrick reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.

SAN FRANCISCO – A simple, low-cost intervention reduces the rate of suicide intent by about one-third among veterans at moderate risk who are discharged from the emergency department, according to a study presented at the annual meeting of the American Psychiatric Association.

The two-part intervention – known as the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment project (SAFE VET) – consists of a safety plan developed in the emergency department plus structured weekly follow-up monitoring post discharge.

Among the 124 veterans included in an interim analysis, about 15% of those in the intervention group had suicide intent at 1 month after discharge, compared with 22% of those in a risk-matched group receiving usual care, reported lead investigator Barbara Stanley, Ph.D., professor and research scientist at Columbia University, New York.

Nearly two-thirds of the veterans in the intervention group reported that they had used their safety plan to avert a suicidal crisis. Furthermore, in comments, the veterans described the intervention as life saving.

"Does SAFE VET ultimately prevent suicide? That question, of course, is out. Do people think this is very, very helpful to them? Very much so," Dr. Stanley commented. "And if you think about this, overall, the expenditure of time is, maximum, 3 hours."

One person attending the session questioned the level of training needed for professionals who help develop the safety plans. "You made it sound pretty easy, and I just wondered, when you are talking about moderate suicide risk patients who are seen cross sectionally, that’s very complicated," he said.

Dr. Stanley responded that doing a safety plan is far easier than conducting a good risk assessment "because you train in it and follow a particular pattern. We have trained people from the level of volunteers answering hotlines up to psychiatrists. If somebody has judged the person is okay to be let go [from the hospital], once you go from that point on, it does not require a lot of professional expertise to do it."

Another attendee asked, "Did you stratify effectiveness by diagnosis or impairment? For example, I could see that cognitively impaired people would do better with a program that reaches out to them, rather than wait for them to come to us."

"No, we kind of took an effectiveness approach in this study; we just took all comers. So if the staff had decided that this person is moderate risk and doesn’t need to be hospitalized, we would include them, period," Dr. Stanley said. "I’m not saying that there won’t be a difference [by diagnosis], because there could be."

SAFE VET intervention

There is good rationale for using ED-based suicide interventions, as the ED is often suicidal patients’ main or only contact with the health care system and many will not follow through with or will have a wait in accessing care after discharge, according to Dr. Stanley.

She contrasted the typical ED approach to suicidal patients and patients with obvious fractures, noting that the latter would never be sent on their way for treatment of the problem at a later time.

"We should figure out a way to have time enough in the ED to do an intervention for our suicidal veterans or suicidal patients, the equivalent of applying a cast in the ED," she maintained.

The safety plan component of SAFE VET is a short prioritized list of coping strategies and resources for use before or during a suicidal crisis that is crafted jointly by the patient and clinician in the ED, but in the patient’s own words (Am. J. Public Health 2012;102[Suppl. 1]:S33-7). It aims to reduce risk, enhance coping, increase treatment motivation, and promote linkages.

The plan has six steps: recognize warning signs, use internal coping strategies, socialize with others who can offer support and distraction, contact family members or friends who can help, contact a mental health agency or professional, and reduce the potential for use of lethal means such as firearms.

The plan has been adopted nationwide at Veterans Affairs Medical Centers in the United States, where a template is used.

With a safety plan in place, "patients feel like they don’t have to ‘white knuckle’ their suicidal episodes anymore because, in the past, what they just did was try to survive it, knowing that time in a certain sense is their friend because the suicidal feelings eventually go away," Dr. Stanley explained. "This gives them something they can do in order to help them through that period of time."

The other component of SAFE VET is structured follow-up monitoring after the patient leaves the ED, typically in the form of weekly telephone calls.

The caller – ideally the same clinician who helped the patient develop the safety plan in the ED – checks on the patient’s mood and risk, reviews and revises the safety plan, discusses access to means, and discusses treatment engagement and helps problem-solve obstacles to getting into treatment.

"Follow-up is important, because this is a very high-risk period. We are potentially saving lives during this period," Dr. Stanley noted. "It’s very low cost – it’s phone contact." On the other hand, "it’s some burden. The big problem is that it requires a shift in the system: Provider systems are not set up for follow-up phone contact," she said.

Study details

The 222 veterans studied were 46 years old on average, and 89% were male. Overall, about one-fourth had a high school education or less and slightly more than half were unemployed.

Interim data among the 124 veterans having adequate follow-up showed that those in the SAFE VET intervention group received a mean of 7.2 follow-up calls.

Compared with their peers in the control group, veterans in the intervention group were less likely at 1 month to have suicidal intent with or without a plan (15% vs. 22%), but the difference diminished thereafter.

"It seems like we are getting our biggest effects at 1 month and then at around 3 months; the groups appear to be equal," commented Dr. Stanley.

In interviews conducted several months after the intervention, 55% of veterans in that group said that it was very helpful for staying safe; 69% and 76% were very satisfied with the safety planning and the follow-up monitoring, respectively, she reported.

Fully 61% of veterans in the intervention group had used their safety plan to avert a suicidal crisis. These users said that the plan helped them contact a professional (50%), contact social support (39%), use an internal coping strategy (26%), and recognize a warning sign of suicidal crisis (21%).

Veterans said that the most helpful aspect of the follow-up calls was regularly checking in (75%) and feeling cared for (58%).

The research was funded by the U.S. Department of Defense and the U.S. Veterans Health Administration.

SAN FRANCISCO – A simple, low-cost intervention reduces the rate of suicide intent by about one-third among veterans at moderate risk who are discharged from the emergency department, according to a study presented at the annual meeting of the American Psychiatric Association.

The two-part intervention – known as the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment project (SAFE VET) – consists of a safety plan developed in the emergency department plus structured weekly follow-up monitoring post discharge.

Among the 124 veterans included in an interim analysis, about 15% of those in the intervention group had suicide intent at 1 month after discharge, compared with 22% of those in a risk-matched group receiving usual care, reported lead investigator Barbara Stanley, Ph.D., professor and research scientist at Columbia University, New York.

Nearly two-thirds of the veterans in the intervention group reported that they had used their safety plan to avert a suicidal crisis. Furthermore, in comments, the veterans described the intervention as life saving.

"Does SAFE VET ultimately prevent suicide? That question, of course, is out. Do people think this is very, very helpful to them? Very much so," Dr. Stanley commented. "And if you think about this, overall, the expenditure of time is, maximum, 3 hours."

One person attending the session questioned the level of training needed for professionals who help develop the safety plans. "You made it sound pretty easy, and I just wondered, when you are talking about moderate suicide risk patients who are seen cross sectionally, that’s very complicated," he said.

Dr. Stanley responded that doing a safety plan is far easier than conducting a good risk assessment "because you train in it and follow a particular pattern. We have trained people from the level of volunteers answering hotlines up to psychiatrists. If somebody has judged the person is okay to be let go [from the hospital], once you go from that point on, it does not require a lot of professional expertise to do it."

Another attendee asked, "Did you stratify effectiveness by diagnosis or impairment? For example, I could see that cognitively impaired people would do better with a program that reaches out to them, rather than wait for them to come to us."

"No, we kind of took an effectiveness approach in this study; we just took all comers. So if the staff had decided that this person is moderate risk and doesn’t need to be hospitalized, we would include them, period," Dr. Stanley said. "I’m not saying that there won’t be a difference [by diagnosis], because there could be."

SAFE VET intervention

There is good rationale for using ED-based suicide interventions, as the ED is often suicidal patients’ main or only contact with the health care system and many will not follow through with or will have a wait in accessing care after discharge, according to Dr. Stanley.

She contrasted the typical ED approach to suicidal patients and patients with obvious fractures, noting that the latter would never be sent on their way for treatment of the problem at a later time.

"We should figure out a way to have time enough in the ED to do an intervention for our suicidal veterans or suicidal patients, the equivalent of applying a cast in the ED," she maintained.

The safety plan component of SAFE VET is a short prioritized list of coping strategies and resources for use before or during a suicidal crisis that is crafted jointly by the patient and clinician in the ED, but in the patient’s own words (Am. J. Public Health 2012;102[Suppl. 1]:S33-7). It aims to reduce risk, enhance coping, increase treatment motivation, and promote linkages.

The plan has six steps: recognize warning signs, use internal coping strategies, socialize with others who can offer support and distraction, contact family members or friends who can help, contact a mental health agency or professional, and reduce the potential for use of lethal means such as firearms.

The plan has been adopted nationwide at Veterans Affairs Medical Centers in the United States, where a template is used.

With a safety plan in place, "patients feel like they don’t have to ‘white knuckle’ their suicidal episodes anymore because, in the past, what they just did was try to survive it, knowing that time in a certain sense is their friend because the suicidal feelings eventually go away," Dr. Stanley explained. "This gives them something they can do in order to help them through that period of time."

The other component of SAFE VET is structured follow-up monitoring after the patient leaves the ED, typically in the form of weekly telephone calls.

The caller – ideally the same clinician who helped the patient develop the safety plan in the ED – checks on the patient’s mood and risk, reviews and revises the safety plan, discusses access to means, and discusses treatment engagement and helps problem-solve obstacles to getting into treatment.

"Follow-up is important, because this is a very high-risk period. We are potentially saving lives during this period," Dr. Stanley noted. "It’s very low cost – it’s phone contact." On the other hand, "it’s some burden. The big problem is that it requires a shift in the system: Provider systems are not set up for follow-up phone contact," she said.

Study details

The 222 veterans studied were 46 years old on average, and 89% were male. Overall, about one-fourth had a high school education or less and slightly more than half were unemployed.

Interim data among the 124 veterans having adequate follow-up showed that those in the SAFE VET intervention group received a mean of 7.2 follow-up calls.

Compared with their peers in the control group, veterans in the intervention group were less likely at 1 month to have suicidal intent with or without a plan (15% vs. 22%), but the difference diminished thereafter.

"It seems like we are getting our biggest effects at 1 month and then at around 3 months; the groups appear to be equal," commented Dr. Stanley.

In interviews conducted several months after the intervention, 55% of veterans in that group said that it was very helpful for staying safe; 69% and 76% were very satisfied with the safety planning and the follow-up monitoring, respectively, she reported.

Fully 61% of veterans in the intervention group had used their safety plan to avert a suicidal crisis. These users said that the plan helped them contact a professional (50%), contact social support (39%), use an internal coping strategy (26%), and recognize a warning sign of suicidal crisis (21%).

Veterans said that the most helpful aspect of the follow-up calls was regularly checking in (75%) and feeling cared for (58%).

The research was funded by the U.S. Department of Defense and the U.S. Veterans Health Administration.

SAN FRANCISCO – A simple, low-cost intervention reduces the rate of suicide intent by about one-third among veterans at moderate risk who are discharged from the emergency department, according to a study presented at the annual meeting of the American Psychiatric Association.

The two-part intervention – known as the Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment project (SAFE VET) – consists of a safety plan developed in the emergency department plus structured weekly follow-up monitoring post discharge.

Among the 124 veterans included in an interim analysis, about 15% of those in the intervention group had suicide intent at 1 month after discharge, compared with 22% of those in a risk-matched group receiving usual care, reported lead investigator Barbara Stanley, Ph.D., professor and research scientist at Columbia University, New York.

Nearly two-thirds of the veterans in the intervention group reported that they had used their safety plan to avert a suicidal crisis. Furthermore, in comments, the veterans described the intervention as life saving.

"Does SAFE VET ultimately prevent suicide? That question, of course, is out. Do people think this is very, very helpful to them? Very much so," Dr. Stanley commented. "And if you think about this, overall, the expenditure of time is, maximum, 3 hours."

One person attending the session questioned the level of training needed for professionals who help develop the safety plans. "You made it sound pretty easy, and I just wondered, when you are talking about moderate suicide risk patients who are seen cross sectionally, that’s very complicated," he said.

Dr. Stanley responded that doing a safety plan is far easier than conducting a good risk assessment "because you train in it and follow a particular pattern. We have trained people from the level of volunteers answering hotlines up to psychiatrists. If somebody has judged the person is okay to be let go [from the hospital], once you go from that point on, it does not require a lot of professional expertise to do it."

Another attendee asked, "Did you stratify effectiveness by diagnosis or impairment? For example, I could see that cognitively impaired people would do better with a program that reaches out to them, rather than wait for them to come to us."

"No, we kind of took an effectiveness approach in this study; we just took all comers. So if the staff had decided that this person is moderate risk and doesn’t need to be hospitalized, we would include them, period," Dr. Stanley said. "I’m not saying that there won’t be a difference [by diagnosis], because there could be."

SAFE VET intervention

There is good rationale for using ED-based suicide interventions, as the ED is often suicidal patients’ main or only contact with the health care system and many will not follow through with or will have a wait in accessing care after discharge, according to Dr. Stanley.

She contrasted the typical ED approach to suicidal patients and patients with obvious fractures, noting that the latter would never be sent on their way for treatment of the problem at a later time.

"We should figure out a way to have time enough in the ED to do an intervention for our suicidal veterans or suicidal patients, the equivalent of applying a cast in the ED," she maintained.

The safety plan component of SAFE VET is a short prioritized list of coping strategies and resources for use before or during a suicidal crisis that is crafted jointly by the patient and clinician in the ED, but in the patient’s own words (Am. J. Public Health 2012;102[Suppl. 1]:S33-7). It aims to reduce risk, enhance coping, increase treatment motivation, and promote linkages.

The plan has six steps: recognize warning signs, use internal coping strategies, socialize with others who can offer support and distraction, contact family members or friends who can help, contact a mental health agency or professional, and reduce the potential for use of lethal means such as firearms.

The plan has been adopted nationwide at Veterans Affairs Medical Centers in the United States, where a template is used.

With a safety plan in place, "patients feel like they don’t have to ‘white knuckle’ their suicidal episodes anymore because, in the past, what they just did was try to survive it, knowing that time in a certain sense is their friend because the suicidal feelings eventually go away," Dr. Stanley explained. "This gives them something they can do in order to help them through that period of time."

The other component of SAFE VET is structured follow-up monitoring after the patient leaves the ED, typically in the form of weekly telephone calls.

The caller – ideally the same clinician who helped the patient develop the safety plan in the ED – checks on the patient’s mood and risk, reviews and revises the safety plan, discusses access to means, and discusses treatment engagement and helps problem-solve obstacles to getting into treatment.

"Follow-up is important, because this is a very high-risk period. We are potentially saving lives during this period," Dr. Stanley noted. "It’s very low cost – it’s phone contact." On the other hand, "it’s some burden. The big problem is that it requires a shift in the system: Provider systems are not set up for follow-up phone contact," she said.

Study details

The 222 veterans studied were 46 years old on average, and 89% were male. Overall, about one-fourth had a high school education or less and slightly more than half were unemployed.

Interim data among the 124 veterans having adequate follow-up showed that those in the SAFE VET intervention group received a mean of 7.2 follow-up calls.

Compared with their peers in the control group, veterans in the intervention group were less likely at 1 month to have suicidal intent with or without a plan (15% vs. 22%), but the difference diminished thereafter.

"It seems like we are getting our biggest effects at 1 month and then at around 3 months; the groups appear to be equal," commented Dr. Stanley.

In interviews conducted several months after the intervention, 55% of veterans in that group said that it was very helpful for staying safe; 69% and 76% were very satisfied with the safety planning and the follow-up monitoring, respectively, she reported.

Fully 61% of veterans in the intervention group had used their safety plan to avert a suicidal crisis. These users said that the plan helped them contact a professional (50%), contact social support (39%), use an internal coping strategy (26%), and recognize a warning sign of suicidal crisis (21%).

Veterans said that the most helpful aspect of the follow-up calls was regularly checking in (75%) and feeling cared for (58%).

The research was funded by the U.S. Department of Defense and the U.S. Veterans Health Administration.

SAN FRANCISCO – A pilot randomized study of 30 patients with treatment-resistant depression suggests that helping them cope with their illness as a chronic disease might be more helpful than focusing exclusively on symptom remission.

Clinicians usually focus on trying to push symptoms of depression into remission using one medication or combination of therapies after another, Dr. Gabor I. Keitner said at the annual meeting of the American Psychiatric Association.

That does not work for many patients, leaving them and their clinicians feeling hopeless and disillusioned. Approximately 40%-60% of people with depression will have symptoms that do not remit, and perhaps 20%-30% of depressed patients might have treatment-resistant depression.

"In many ways, we’ve been looking at the wrong side of the equation," said Dr. Keitner, professor of psychiatry and human behavior at Brown University, Providence, R.I. Instead of throwing one drug or procedure after another at the symptoms, perhaps clinicians should interrupt this "endless, vicious cycle" and help patients with treatment-resistant depression reframe the approach, he said. Clinicians could teach ways to improve function while living with chronic depression, much as other clinicians employ blame-free approaches to helping patients manage diabetes or other chronic diseases.

Dr. Keitner and his associates created a management of depression program at his institution to do just that. Most patients who come to the program are on six, seven, even eight medications for depression when they arrive.

Among 30 adults with treatment-resistant depression who finished the 12-week pilot study, 17 were randomized to the management of depression program and 13 to treatment as usual, which involved continuing any medication or psychotherapy being used and monthly telephone contacts.

The intervention group also continued any therapies being used and added nine adjunctive management of depression sessions, which provided education about persistent depression, helped set realistic expectations, and focused on living fully in the context of persisting symptoms. Other topics included healthy living habits (diet, exercise, sleep, and relaxation techniques), the important of relationships, strategies for communication and emotional problem-solving, and a focus on meaning and purpose in life.

Patients had been depressed for 20 years, on average. Compared with the control group, the intervention group had more patients with severe depression and with borderline personality disorder, though the groups’ characteristics did not differ significantly, probably because of the small cohorts, Dr. Keitner said. The study defined treatment-resistant depression as failure to respond to at least two adequate courses of pharmacologic therapy for depression.

After 12 weeks, depressive symptoms improved significantly in both groups. Patients in both groups still had moderate depression, but the intervention group moved from more severe to moderate depression, Dr. Keitner reported. Patients in the management of depression group but not in the control group also showed significantly improved scores on measures of perceived social support and purpose in life.

Mean self-reported depression severity scores on the Beck Depression Inventory (BDI) improved from 32 at baseline to 22 at 12 weeks in the management of depression group and from 35 to 26 in the control group. Clinician-rated depression severity scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) improved from 33 at baseline to 26 at 12 weeks in the intervention group and from 31 to 23 in the control group.

Social support scores on the Mood and Physical Symptoms Scale (MPSS) improved from 4.2 at baseline to 3.4 at 12 weeks in the intervention group and from 4.1 to 3.6 in the control group. Scores for purpose in life, assessed on the Scales of Psychological Well-Being (SPWB), improved from 2.6 to 3.0 in the intervention group and from 2.9 to 3.2 in the control group. The changes in both these measures were significant for the intervention group but not the control group.

The increased attention provided to patients in the control group from being in the study might have led to improved symptoms, suggesting that all patients with treatment-resistant depression might benefit from ongoing involvement in treatment, Dr. Keitner said. Broadening the therapeutic focus beyond symptoms might have additional benefits, the findings suggest.

Of course, larger studies are needed to replicate the findings. Future iterations of the management of depression program will include modules on emotion regulation and distress tolerance to help patients with comorbid borderline personality disorder and treatment-resistant depression. Dr. Keitner also plans to increase the number of sessions from 9 to 16 in future studies and to incorporate telehealth strategies to improve adherence in patients who have difficulty coming for therapy.

"I think we’re moving toward a recognition that focusing on symptom reduction is illusory, and broadening our therapeutic options," he said. There’s been too great a focus on magic-bullet drugs, he believes. Approaches that combine medication, devices, and psychosocial interventions are important, and the treatment focus should broaden to include social and work functioning, treatment adherence, access to care, and reduced costs.

Dr. Keitner published a description of his program in 2012 (Psychiatr. Clin. North Am. 2012;35:249-65).

Some critics of this new approach fear it is nihilistic, and that telling patients there is no cure for their symptoms will lead to increased suicides, he added. That has not been the case, in his experience. "You’re not telling them anything they don’t know. They have an illness that’s not going to go away," he said. By definition, there are no effective treatments for treatment-resistant depression.

The study excluded patients with bipolar or psychotic disorders, acutely suicidal or substance-abusing patients, and patients currently receiving electroconvulsive therapy.

Dr. Keitner reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – A pilot randomized study of 30 patients with treatment-resistant depression suggests that helping them cope with their illness as a chronic disease might be more helpful than focusing exclusively on symptom remission.

Clinicians usually focus on trying to push symptoms of depression into remission using one medication or combination of therapies after another, Dr. Gabor I. Keitner said at the annual meeting of the American Psychiatric Association.

That does not work for many patients, leaving them and their clinicians feeling hopeless and disillusioned. Approximately 40%-60% of people with depression will have symptoms that do not remit, and perhaps 20%-30% of depressed patients might have treatment-resistant depression.

"In many ways, we’ve been looking at the wrong side of the equation," said Dr. Keitner, professor of psychiatry and human behavior at Brown University, Providence, R.I. Instead of throwing one drug or procedure after another at the symptoms, perhaps clinicians should interrupt this "endless, vicious cycle" and help patients with treatment-resistant depression reframe the approach, he said. Clinicians could teach ways to improve function while living with chronic depression, much as other clinicians employ blame-free approaches to helping patients manage diabetes or other chronic diseases.

Dr. Keitner and his associates created a management of depression program at his institution to do just that. Most patients who come to the program are on six, seven, even eight medications for depression when they arrive.

Among 30 adults with treatment-resistant depression who finished the 12-week pilot study, 17 were randomized to the management of depression program and 13 to treatment as usual, which involved continuing any medication or psychotherapy being used and monthly telephone contacts.

The intervention group also continued any therapies being used and added nine adjunctive management of depression sessions, which provided education about persistent depression, helped set realistic expectations, and focused on living fully in the context of persisting symptoms. Other topics included healthy living habits (diet, exercise, sleep, and relaxation techniques), the important of relationships, strategies for communication and emotional problem-solving, and a focus on meaning and purpose in life.

Patients had been depressed for 20 years, on average. Compared with the control group, the intervention group had more patients with severe depression and with borderline personality disorder, though the groups’ characteristics did not differ significantly, probably because of the small cohorts, Dr. Keitner said. The study defined treatment-resistant depression as failure to respond to at least two adequate courses of pharmacologic therapy for depression.

After 12 weeks, depressive symptoms improved significantly in both groups. Patients in both groups still had moderate depression, but the intervention group moved from more severe to moderate depression, Dr. Keitner reported. Patients in the management of depression group but not in the control group also showed significantly improved scores on measures of perceived social support and purpose in life.

Mean self-reported depression severity scores on the Beck Depression Inventory (BDI) improved from 32 at baseline to 22 at 12 weeks in the management of depression group and from 35 to 26 in the control group. Clinician-rated depression severity scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) improved from 33 at baseline to 26 at 12 weeks in the intervention group and from 31 to 23 in the control group.

Social support scores on the Mood and Physical Symptoms Scale (MPSS) improved from 4.2 at baseline to 3.4 at 12 weeks in the intervention group and from 4.1 to 3.6 in the control group. Scores for purpose in life, assessed on the Scales of Psychological Well-Being (SPWB), improved from 2.6 to 3.0 in the intervention group and from 2.9 to 3.2 in the control group. The changes in both these measures were significant for the intervention group but not the control group.

The increased attention provided to patients in the control group from being in the study might have led to improved symptoms, suggesting that all patients with treatment-resistant depression might benefit from ongoing involvement in treatment, Dr. Keitner said. Broadening the therapeutic focus beyond symptoms might have additional benefits, the findings suggest.

Of course, larger studies are needed to replicate the findings. Future iterations of the management of depression program will include modules on emotion regulation and distress tolerance to help patients with comorbid borderline personality disorder and treatment-resistant depression. Dr. Keitner also plans to increase the number of sessions from 9 to 16 in future studies and to incorporate telehealth strategies to improve adherence in patients who have difficulty coming for therapy.

"I think we’re moving toward a recognition that focusing on symptom reduction is illusory, and broadening our therapeutic options," he said. There’s been too great a focus on magic-bullet drugs, he believes. Approaches that combine medication, devices, and psychosocial interventions are important, and the treatment focus should broaden to include social and work functioning, treatment adherence, access to care, and reduced costs.

Dr. Keitner published a description of his program in 2012 (Psychiatr. Clin. North Am. 2012;35:249-65).

Some critics of this new approach fear it is nihilistic, and that telling patients there is no cure for their symptoms will lead to increased suicides, he added. That has not been the case, in his experience. "You’re not telling them anything they don’t know. They have an illness that’s not going to go away," he said. By definition, there are no effective treatments for treatment-resistant depression.

The study excluded patients with bipolar or psychotic disorders, acutely suicidal or substance-abusing patients, and patients currently receiving electroconvulsive therapy.

Dr. Keitner reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – A pilot randomized study of 30 patients with treatment-resistant depression suggests that helping them cope with their illness as a chronic disease might be more helpful than focusing exclusively on symptom remission.

Clinicians usually focus on trying to push symptoms of depression into remission using one medication or combination of therapies after another, Dr. Gabor I. Keitner said at the annual meeting of the American Psychiatric Association.

That does not work for many patients, leaving them and their clinicians feeling hopeless and disillusioned. Approximately 40%-60% of people with depression will have symptoms that do not remit, and perhaps 20%-30% of depressed patients might have treatment-resistant depression.

"In many ways, we’ve been looking at the wrong side of the equation," said Dr. Keitner, professor of psychiatry and human behavior at Brown University, Providence, R.I. Instead of throwing one drug or procedure after another at the symptoms, perhaps clinicians should interrupt this "endless, vicious cycle" and help patients with treatment-resistant depression reframe the approach, he said. Clinicians could teach ways to improve function while living with chronic depression, much as other clinicians employ blame-free approaches to helping patients manage diabetes or other chronic diseases.

Dr. Keitner and his associates created a management of depression program at his institution to do just that. Most patients who come to the program are on six, seven, even eight medications for depression when they arrive.

Among 30 adults with treatment-resistant depression who finished the 12-week pilot study, 17 were randomized to the management of depression program and 13 to treatment as usual, which involved continuing any medication or psychotherapy being used and monthly telephone contacts.

The intervention group also continued any therapies being used and added nine adjunctive management of depression sessions, which provided education about persistent depression, helped set realistic expectations, and focused on living fully in the context of persisting symptoms. Other topics included healthy living habits (diet, exercise, sleep, and relaxation techniques), the important of relationships, strategies for communication and emotional problem-solving, and a focus on meaning and purpose in life.

Patients had been depressed for 20 years, on average. Compared with the control group, the intervention group had more patients with severe depression and with borderline personality disorder, though the groups’ characteristics did not differ significantly, probably because of the small cohorts, Dr. Keitner said. The study defined treatment-resistant depression as failure to respond to at least two adequate courses of pharmacologic therapy for depression.

After 12 weeks, depressive symptoms improved significantly in both groups. Patients in both groups still had moderate depression, but the intervention group moved from more severe to moderate depression, Dr. Keitner reported. Patients in the management of depression group but not in the control group also showed significantly improved scores on measures of perceived social support and purpose in life.

Mean self-reported depression severity scores on the Beck Depression Inventory (BDI) improved from 32 at baseline to 22 at 12 weeks in the management of depression group and from 35 to 26 in the control group. Clinician-rated depression severity scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) improved from 33 at baseline to 26 at 12 weeks in the intervention group and from 31 to 23 in the control group.

Social support scores on the Mood and Physical Symptoms Scale (MPSS) improved from 4.2 at baseline to 3.4 at 12 weeks in the intervention group and from 4.1 to 3.6 in the control group. Scores for purpose in life, assessed on the Scales of Psychological Well-Being (SPWB), improved from 2.6 to 3.0 in the intervention group and from 2.9 to 3.2 in the control group. The changes in both these measures were significant for the intervention group but not the control group.

The increased attention provided to patients in the control group from being in the study might have led to improved symptoms, suggesting that all patients with treatment-resistant depression might benefit from ongoing involvement in treatment, Dr. Keitner said. Broadening the therapeutic focus beyond symptoms might have additional benefits, the findings suggest.

Of course, larger studies are needed to replicate the findings. Future iterations of the management of depression program will include modules on emotion regulation and distress tolerance to help patients with comorbid borderline personality disorder and treatment-resistant depression. Dr. Keitner also plans to increase the number of sessions from 9 to 16 in future studies and to incorporate telehealth strategies to improve adherence in patients who have difficulty coming for therapy.

"I think we’re moving toward a recognition that focusing on symptom reduction is illusory, and broadening our therapeutic options," he said. There’s been too great a focus on magic-bullet drugs, he believes. Approaches that combine medication, devices, and psychosocial interventions are important, and the treatment focus should broaden to include social and work functioning, treatment adherence, access to care, and reduced costs.

Dr. Keitner published a description of his program in 2012 (Psychiatr. Clin. North Am. 2012;35:249-65).

Some critics of this new approach fear it is nihilistic, and that telling patients there is no cure for their symptoms will lead to increased suicides, he added. That has not been the case, in his experience. "You’re not telling them anything they don’t know. They have an illness that’s not going to go away," he said. By definition, there are no effective treatments for treatment-resistant depression.

The study excluded patients with bipolar or psychotic disorders, acutely suicidal or substance-abusing patients, and patients currently receiving electroconvulsive therapy.

Dr. Keitner reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert