APA Institute on Pyschiatric Services 2012

NEW YORK – The National Institute of Mental Health is putting its research and clinical muscle into determining whether early intervention in schizophrenia can improve outcomes later in life.

The Recovery After an Initial Schizophrenia Episode (RAISE) program, a research project of the NIMH, will test "whether early, aggressive, and preemptive intervention can slow or halt clinical and functional deterioration in schizophrenia," Amy Goldstein, Ph.D., said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Goldstein, who is associate director of the RAISE initiative, and her colleagues described the ambitious project, which includes a randomized clinical trial of community-based treatment, as well as a component for limiting disability from schizophrenia and promoting recovery through integrated care.

Instead of focusing on the management of established illness and entrenched disability in people with schizophrenia, RAISE is comparing the effectiveness of a phase-specific intervention for first-episode psychosis with usual community care. The RAISE investigators also are conducting an implementation study to determine which factors hinder and which facilitate quick adoption of early psychosis interventions.

With early treatment, patients tend to have better responses to antipsychotic medications and experience better outcomes with social and vocational rehabilitation programs. In addition, early intervention has "a greater impact for psychological therapies that target residual symptoms, behavioral adaptation, and quality of life," said Dr. Goldstein, who also is chief of the NIMH Preventive Intervention Program.

RAISE ETP

The RAISE ETP (Early Treatment Programs) trial pits the RAISE "Navigate" model for community-based treatment of patients with first-episode psychosis with standard care. Navigate uses a team-based approach to provide patients with individualized psychopharmacology, individual resiliency training, family psychoeducation, and supported employment and/or education, said coinvestigator Dr. Delbert G. Robinson of Hofstra North Shore-Long Island Jewish School of Medicine in Hempstead, N.Y.

The medication component is supported by an online tool that can be used on desktop, laptop, and tablet computers. The tool combines clinician ratings, clinical findings, and patient self-reports to help identify the optimum medication for each patient.

In the ongoing RAISE ETP clinical trial, patients are randomized for a minimum of 2 years to the Navigate program or to a currently available treatment program at a community center. The programs are judged by clinical raters masked to randomization who conduct live, two-way video interviews to assess diagnosis and outcomes.

Although it is still too early to analyze the data, it is encouraging that the community centers participating in the trial were able to recruit 404 patients, and the study thus far has demonstrated that community centers with no previous experience in treating first-episode psychosis can provide integrated treatment, Dr. Robinson said.

"This is an RCT [randomized controlled trial] where the primary outcome measure is not symptoms, it’s quality of life," he said.

RAISE Connection

The RAISE Connection Program is a two-site demonstration study of an intervention designed to limit the disability of patients with early-stage psychotic disorders by helping with recovery, empowerment, skills training, and personalized support, said Dr. Lisa B. Dixon, of the University of Maryland, Baltimore.

"With first-episode [psychosis], you don’t have people who think they have an illness; in fact, in most cases, they’re quite certain they don’t. So part of what we’re doing is to try to help them set the stage and develop a set of attitudes and relationships to their illness that will be durable lifelong," she said.

The Connection team includes a full-time master’s-level clinician as team leader; a 0.20-0.25 full-time equivalent psychiatrist; a full-time supportive employment and education specialist; and a half-time recovery coach who deals with issues of self-management, substance abuse, and family.

For the first 1-3 months, the team strives to develop trusting relationships with the patient and his family and to identify community support, minimize stigma, and maintain continuity of care. The care includes home visits, meetings with caregivers, escorting patients to treatment, if needed, and ensuring that they have adequate housing and financial resources.

Over months 4-21, the staff help patients with social skills, wellness, and communications by mediating conflicts and helping the patient and his family and friends with coping and relapse-prevention strategies.

In the final phase, usually months 22-24, patients are helped with the transition to long-term care and community support.

Dr. Dixon described the Connection program as a cross between Critical Time Intervention programs, Assertive Community Treatment interventions, employment agencies, and drop-in centers.

"This model best fits a region with sufficient population density to support a fully dedicated team. A very big challenge for the field is how to position this kind of a model within an overall treatment continuum," she concluded.

Dr. Goldstein and Dr. Dixon reported that they had no relevant disclosures. Dr. Robinson has received grant support from the NIMH. Bristol-Myers Squibb and Janssen have supplied medication for the research.

Further information about the RAISE initiative is available here.

NEW YORK – The National Institute of Mental Health is putting its research and clinical muscle into determining whether early intervention in schizophrenia can improve outcomes later in life.

The Recovery After an Initial Schizophrenia Episode (RAISE) program, a research project of the NIMH, will test "whether early, aggressive, and preemptive intervention can slow or halt clinical and functional deterioration in schizophrenia," Amy Goldstein, Ph.D., said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Goldstein, who is associate director of the RAISE initiative, and her colleagues described the ambitious project, which includes a randomized clinical trial of community-based treatment, as well as a component for limiting disability from schizophrenia and promoting recovery through integrated care.

Instead of focusing on the management of established illness and entrenched disability in people with schizophrenia, RAISE is comparing the effectiveness of a phase-specific intervention for first-episode psychosis with usual community care. The RAISE investigators also are conducting an implementation study to determine which factors hinder and which facilitate quick adoption of early psychosis interventions.

With early treatment, patients tend to have better responses to antipsychotic medications and experience better outcomes with social and vocational rehabilitation programs. In addition, early intervention has "a greater impact for psychological therapies that target residual symptoms, behavioral adaptation, and quality of life," said Dr. Goldstein, who also is chief of the NIMH Preventive Intervention Program.

RAISE ETP

The RAISE ETP (Early Treatment Programs) trial pits the RAISE "Navigate" model for community-based treatment of patients with first-episode psychosis with standard care. Navigate uses a team-based approach to provide patients with individualized psychopharmacology, individual resiliency training, family psychoeducation, and supported employment and/or education, said coinvestigator Dr. Delbert G. Robinson of Hofstra North Shore-Long Island Jewish School of Medicine in Hempstead, N.Y.

The medication component is supported by an online tool that can be used on desktop, laptop, and tablet computers. The tool combines clinician ratings, clinical findings, and patient self-reports to help identify the optimum medication for each patient.

In the ongoing RAISE ETP clinical trial, patients are randomized for a minimum of 2 years to the Navigate program or to a currently available treatment program at a community center. The programs are judged by clinical raters masked to randomization who conduct live, two-way video interviews to assess diagnosis and outcomes.

Although it is still too early to analyze the data, it is encouraging that the community centers participating in the trial were able to recruit 404 patients, and the study thus far has demonstrated that community centers with no previous experience in treating first-episode psychosis can provide integrated treatment, Dr. Robinson said.

"This is an RCT [randomized controlled trial] where the primary outcome measure is not symptoms, it’s quality of life," he said.

RAISE Connection

The RAISE Connection Program is a two-site demonstration study of an intervention designed to limit the disability of patients with early-stage psychotic disorders by helping with recovery, empowerment, skills training, and personalized support, said Dr. Lisa B. Dixon, of the University of Maryland, Baltimore.

"With first-episode [psychosis], you don’t have people who think they have an illness; in fact, in most cases, they’re quite certain they don’t. So part of what we’re doing is to try to help them set the stage and develop a set of attitudes and relationships to their illness that will be durable lifelong," she said.

The Connection team includes a full-time master’s-level clinician as team leader; a 0.20-0.25 full-time equivalent psychiatrist; a full-time supportive employment and education specialist; and a half-time recovery coach who deals with issues of self-management, substance abuse, and family.

For the first 1-3 months, the team strives to develop trusting relationships with the patient and his family and to identify community support, minimize stigma, and maintain continuity of care. The care includes home visits, meetings with caregivers, escorting patients to treatment, if needed, and ensuring that they have adequate housing and financial resources.

Over months 4-21, the staff help patients with social skills, wellness, and communications by mediating conflicts and helping the patient and his family and friends with coping and relapse-prevention strategies.

In the final phase, usually months 22-24, patients are helped with the transition to long-term care and community support.

Dr. Dixon described the Connection program as a cross between Critical Time Intervention programs, Assertive Community Treatment interventions, employment agencies, and drop-in centers.

"This model best fits a region with sufficient population density to support a fully dedicated team. A very big challenge for the field is how to position this kind of a model within an overall treatment continuum," she concluded.

Dr. Goldstein and Dr. Dixon reported that they had no relevant disclosures. Dr. Robinson has received grant support from the NIMH. Bristol-Myers Squibb and Janssen have supplied medication for the research.

Further information about the RAISE initiative is available here.

NEW YORK – The National Institute of Mental Health is putting its research and clinical muscle into determining whether early intervention in schizophrenia can improve outcomes later in life.

The Recovery After an Initial Schizophrenia Episode (RAISE) program, a research project of the NIMH, will test "whether early, aggressive, and preemptive intervention can slow or halt clinical and functional deterioration in schizophrenia," Amy Goldstein, Ph.D., said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Goldstein, who is associate director of the RAISE initiative, and her colleagues described the ambitious project, which includes a randomized clinical trial of community-based treatment, as well as a component for limiting disability from schizophrenia and promoting recovery through integrated care.

Instead of focusing on the management of established illness and entrenched disability in people with schizophrenia, RAISE is comparing the effectiveness of a phase-specific intervention for first-episode psychosis with usual community care. The RAISE investigators also are conducting an implementation study to determine which factors hinder and which facilitate quick adoption of early psychosis interventions.

With early treatment, patients tend to have better responses to antipsychotic medications and experience better outcomes with social and vocational rehabilitation programs. In addition, early intervention has "a greater impact for psychological therapies that target residual symptoms, behavioral adaptation, and quality of life," said Dr. Goldstein, who also is chief of the NIMH Preventive Intervention Program.

RAISE ETP

The RAISE ETP (Early Treatment Programs) trial pits the RAISE "Navigate" model for community-based treatment of patients with first-episode psychosis with standard care. Navigate uses a team-based approach to provide patients with individualized psychopharmacology, individual resiliency training, family psychoeducation, and supported employment and/or education, said coinvestigator Dr. Delbert G. Robinson of Hofstra North Shore-Long Island Jewish School of Medicine in Hempstead, N.Y.

The medication component is supported by an online tool that can be used on desktop, laptop, and tablet computers. The tool combines clinician ratings, clinical findings, and patient self-reports to help identify the optimum medication for each patient.

In the ongoing RAISE ETP clinical trial, patients are randomized for a minimum of 2 years to the Navigate program or to a currently available treatment program at a community center. The programs are judged by clinical raters masked to randomization who conduct live, two-way video interviews to assess diagnosis and outcomes.

Although it is still too early to analyze the data, it is encouraging that the community centers participating in the trial were able to recruit 404 patients, and the study thus far has demonstrated that community centers with no previous experience in treating first-episode psychosis can provide integrated treatment, Dr. Robinson said.

"This is an RCT [randomized controlled trial] where the primary outcome measure is not symptoms, it’s quality of life," he said.

RAISE Connection

The RAISE Connection Program is a two-site demonstration study of an intervention designed to limit the disability of patients with early-stage psychotic disorders by helping with recovery, empowerment, skills training, and personalized support, said Dr. Lisa B. Dixon, of the University of Maryland, Baltimore.

"With first-episode [psychosis], you don’t have people who think they have an illness; in fact, in most cases, they’re quite certain they don’t. So part of what we’re doing is to try to help them set the stage and develop a set of attitudes and relationships to their illness that will be durable lifelong," she said.

The Connection team includes a full-time master’s-level clinician as team leader; a 0.20-0.25 full-time equivalent psychiatrist; a full-time supportive employment and education specialist; and a half-time recovery coach who deals with issues of self-management, substance abuse, and family.

For the first 1-3 months, the team strives to develop trusting relationships with the patient and his family and to identify community support, minimize stigma, and maintain continuity of care. The care includes home visits, meetings with caregivers, escorting patients to treatment, if needed, and ensuring that they have adequate housing and financial resources.

Over months 4-21, the staff help patients with social skills, wellness, and communications by mediating conflicts and helping the patient and his family and friends with coping and relapse-prevention strategies.

In the final phase, usually months 22-24, patients are helped with the transition to long-term care and community support.

Dr. Dixon described the Connection program as a cross between Critical Time Intervention programs, Assertive Community Treatment interventions, employment agencies, and drop-in centers.

"This model best fits a region with sufficient population density to support a fully dedicated team. A very big challenge for the field is how to position this kind of a model within an overall treatment continuum," she concluded.

Dr. Goldstein and Dr. Dixon reported that they had no relevant disclosures. Dr. Robinson has received grant support from the NIMH. Bristol-Myers Squibb and Janssen have supplied medication for the research.

Further information about the RAISE initiative is available here.

NEW YORK – Many older adults with a history of chronic schizophrenia can have a sustained remission if they receive appropriate psychosocial stimulation and support, according to Dr. Dilip V. Jeste.

Schizophrenia is a less important barrier to successful aging than are societal attitudes, health care disparity, and scientific or clinical biases, said Dr. Jeste, president of the American Psychiatric Association and chief of geriatric psychiatry at the University of California, San Diego (UCSD).

Optimizing pharmacotherapy, psychosocial interventions, diet, and exercise; curbing substance abuse; and adopting a positive approach on the part of clinicians, patients, and their families can help people with schizophrenia move gently into old age, Dr. Jeste said.

He and his UCSD colleague, Barton W. Palmer, Ph.D., proposed "a new positive psychiatry of aging," a model "that would focus on recovery, promotion of successful aging, neuroplasticity, prevention, and interventions to enhance positive psychological traits such as resilience, optimism, social engagement, and wisdom."

Currently, people with chronic schizophrenia face many obstacles to successful aging, including stigma, poverty, and lack of insurance. But they also face long-held biases of some scientists and clinicians who regard schizophrenia as intractable, as well as facing physical comorbidities such as metabolic syndrome, seen in one study in 60% of middle-aged and older individuals with schizophrenia (J. Clin. Psychopharmacol. 2009;29:210-5). In another study, investigators found that the Framingham 10-year risk of coronary heart disease rose by nearly 80% in middle-aged and older patients with schizophrenia (Schizophr. Res. 2001;125:295-9), Dr. Jeste noted.

People with schizophrenia characteristically have higher levels of stress, tobacco use, and alcohol and substance use, and are more likely to have a sedentary lifestyle. These factors often are exacerbated by poor health care, in addition to the biology of schizophrenia itself. Also, schizophrenia patients are affected by the adverse effects associated with medications such as atypical antipsychotics, which often are associated with weight gain and increased risk for type 2 diabetes, hyperlipidemia, and other cardio- and cerebrovascular disorders.

For these reasons, mortality in schizophrenia is higher than in the general population. For example, in a Finnish study, investigators found a 23-year gap in life expectancy between people with schizophrenia at age 20 and their age-matched peers in the general population. At age 40, the investigators found a 17-year discrepancy (Lancet 2009 July 13 [doi:10.1016/S0140-6736(09)60742-X]).

UCSD investigators have looked at more than 1,400 middle-aged and older people with schizophrenia, nearly 80% of whom had prodromal symptoms of the disorder before the age of 40. In longitudinal follow-up with clinical, neuropsychological, and functional evaluations, the investigators found that people with schizophrenia who were adequately treated had a relatively stable course, improvement over time in psychotic symptoms, and a rate of age-related cognitive change similar to that of people without schizophrenia (Acta Psychiatrica Scandinavica 2003;107:336-43).

As would be expected, people with schizophrenia experienced age-related declines in physical health, but they also reported improvements in mental health, as measured by self-rated quality of life, the authors found (Schizophr. Res. 2009;108:207-13).

Predictors of sustained remission include social support, being or having been married, having comparatively greater cognitive and personality reserve, and getting early treatment. However, neither age nor duration of schizophrenia are accurate predictors of successful, sustained remission, Dr. Jeste emphasized.

He cited two of the best-known examples of successful recovery/remission of people who had lived for decades with schizophrenia: John F. Nash, Ph.D., a 1994 winner of the Nobel Prize in Economic Sciences and the subject of the book (and later the film) "A Beautiful Mind" (New York: Simon & Schuster, 1998) and Elyn R. Saks, Ph.D., professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California in Los Angeles. Dr. Saks chronicled her lifelong struggle with psychosis in the memoir "The Center Cannot Hold: My Journey Through Madness" (New York: Hyperion, 2007).

Although they are neither curative nor specific, antipsychotics might help control acute psychotic symptoms and prevent relapse in older patients. However, these drugs do not do much to help with day-to-day function, and carry increased risks of the adverse effects noted earlier. It is important to remember that the Food and Drug Administration issued a public health advisory in 2005 on the treatment of elderly patients with dementia with antipsychotics.

Psychosocial interventions such as cognitive-behavioral therapy and social skills training, functional adaptation training, diabetes awareness, vocational rehabilitation, and other programs also can have significant positive effects on older people with schizophrenia, Dr. Jeste said. The evidence stands in direct contradiction to Freud’s 1924 dictum that "old people are no longer educable," Dr. Jeste noted.

A relatively new treatment approach is mobile intervention, in which smart phones or other communication devices are used to coach patients, promote self-management, and improve their coping skills.

In addition, Dr. Jeste suggested, more studies are needed to see whether the protective benefits of resilience, optimism, and social engagement seen in healthy older adults hold true for people with chronic severe mental illness.

Dr. Jeste reported that he has no financial relationships with the pharmaceutical industry.

NEW YORK – Many older adults with a history of chronic schizophrenia can have a sustained remission if they receive appropriate psychosocial stimulation and support, according to Dr. Dilip V. Jeste.

Schizophrenia is a less important barrier to successful aging than are societal attitudes, health care disparity, and scientific or clinical biases, said Dr. Jeste, president of the American Psychiatric Association and chief of geriatric psychiatry at the University of California, San Diego (UCSD).

Optimizing pharmacotherapy, psychosocial interventions, diet, and exercise; curbing substance abuse; and adopting a positive approach on the part of clinicians, patients, and their families can help people with schizophrenia move gently into old age, Dr. Jeste said.

He and his UCSD colleague, Barton W. Palmer, Ph.D., proposed "a new positive psychiatry of aging," a model "that would focus on recovery, promotion of successful aging, neuroplasticity, prevention, and interventions to enhance positive psychological traits such as resilience, optimism, social engagement, and wisdom."

Currently, people with chronic schizophrenia face many obstacles to successful aging, including stigma, poverty, and lack of insurance. But they also face long-held biases of some scientists and clinicians who regard schizophrenia as intractable, as well as facing physical comorbidities such as metabolic syndrome, seen in one study in 60% of middle-aged and older individuals with schizophrenia (J. Clin. Psychopharmacol. 2009;29:210-5). In another study, investigators found that the Framingham 10-year risk of coronary heart disease rose by nearly 80% in middle-aged and older patients with schizophrenia (Schizophr. Res. 2001;125:295-9), Dr. Jeste noted.

People with schizophrenia characteristically have higher levels of stress, tobacco use, and alcohol and substance use, and are more likely to have a sedentary lifestyle. These factors often are exacerbated by poor health care, in addition to the biology of schizophrenia itself. Also, schizophrenia patients are affected by the adverse effects associated with medications such as atypical antipsychotics, which often are associated with weight gain and increased risk for type 2 diabetes, hyperlipidemia, and other cardio- and cerebrovascular disorders.

For these reasons, mortality in schizophrenia is higher than in the general population. For example, in a Finnish study, investigators found a 23-year gap in life expectancy between people with schizophrenia at age 20 and their age-matched peers in the general population. At age 40, the investigators found a 17-year discrepancy (Lancet 2009 July 13 [doi:10.1016/S0140-6736(09)60742-X]).

UCSD investigators have looked at more than 1,400 middle-aged and older people with schizophrenia, nearly 80% of whom had prodromal symptoms of the disorder before the age of 40. In longitudinal follow-up with clinical, neuropsychological, and functional evaluations, the investigators found that people with schizophrenia who were adequately treated had a relatively stable course, improvement over time in psychotic symptoms, and a rate of age-related cognitive change similar to that of people without schizophrenia (Acta Psychiatrica Scandinavica 2003;107:336-43).

As would be expected, people with schizophrenia experienced age-related declines in physical health, but they also reported improvements in mental health, as measured by self-rated quality of life, the authors found (Schizophr. Res. 2009;108:207-13).

Predictors of sustained remission include social support, being or having been married, having comparatively greater cognitive and personality reserve, and getting early treatment. However, neither age nor duration of schizophrenia are accurate predictors of successful, sustained remission, Dr. Jeste emphasized.

He cited two of the best-known examples of successful recovery/remission of people who had lived for decades with schizophrenia: John F. Nash, Ph.D., a 1994 winner of the Nobel Prize in Economic Sciences and the subject of the book (and later the film) "A Beautiful Mind" (New York: Simon & Schuster, 1998) and Elyn R. Saks, Ph.D., professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California in Los Angeles. Dr. Saks chronicled her lifelong struggle with psychosis in the memoir "The Center Cannot Hold: My Journey Through Madness" (New York: Hyperion, 2007).

Although they are neither curative nor specific, antipsychotics might help control acute psychotic symptoms and prevent relapse in older patients. However, these drugs do not do much to help with day-to-day function, and carry increased risks of the adverse effects noted earlier. It is important to remember that the Food and Drug Administration issued a public health advisory in 2005 on the treatment of elderly patients with dementia with antipsychotics.

Psychosocial interventions such as cognitive-behavioral therapy and social skills training, functional adaptation training, diabetes awareness, vocational rehabilitation, and other programs also can have significant positive effects on older people with schizophrenia, Dr. Jeste said. The evidence stands in direct contradiction to Freud’s 1924 dictum that "old people are no longer educable," Dr. Jeste noted.

A relatively new treatment approach is mobile intervention, in which smart phones or other communication devices are used to coach patients, promote self-management, and improve their coping skills.

In addition, Dr. Jeste suggested, more studies are needed to see whether the protective benefits of resilience, optimism, and social engagement seen in healthy older adults hold true for people with chronic severe mental illness.

Dr. Jeste reported that he has no financial relationships with the pharmaceutical industry.

NEW YORK – Many older adults with a history of chronic schizophrenia can have a sustained remission if they receive appropriate psychosocial stimulation and support, according to Dr. Dilip V. Jeste.

Schizophrenia is a less important barrier to successful aging than are societal attitudes, health care disparity, and scientific or clinical biases, said Dr. Jeste, president of the American Psychiatric Association and chief of geriatric psychiatry at the University of California, San Diego (UCSD).

Optimizing pharmacotherapy, psychosocial interventions, diet, and exercise; curbing substance abuse; and adopting a positive approach on the part of clinicians, patients, and their families can help people with schizophrenia move gently into old age, Dr. Jeste said.

He and his UCSD colleague, Barton W. Palmer, Ph.D., proposed "a new positive psychiatry of aging," a model "that would focus on recovery, promotion of successful aging, neuroplasticity, prevention, and interventions to enhance positive psychological traits such as resilience, optimism, social engagement, and wisdom."

Currently, people with chronic schizophrenia face many obstacles to successful aging, including stigma, poverty, and lack of insurance. But they also face long-held biases of some scientists and clinicians who regard schizophrenia as intractable, as well as facing physical comorbidities such as metabolic syndrome, seen in one study in 60% of middle-aged and older individuals with schizophrenia (J. Clin. Psychopharmacol. 2009;29:210-5). In another study, investigators found that the Framingham 10-year risk of coronary heart disease rose by nearly 80% in middle-aged and older patients with schizophrenia (Schizophr. Res. 2001;125:295-9), Dr. Jeste noted.

People with schizophrenia characteristically have higher levels of stress, tobacco use, and alcohol and substance use, and are more likely to have a sedentary lifestyle. These factors often are exacerbated by poor health care, in addition to the biology of schizophrenia itself. Also, schizophrenia patients are affected by the adverse effects associated with medications such as atypical antipsychotics, which often are associated with weight gain and increased risk for type 2 diabetes, hyperlipidemia, and other cardio- and cerebrovascular disorders.

For these reasons, mortality in schizophrenia is higher than in the general population. For example, in a Finnish study, investigators found a 23-year gap in life expectancy between people with schizophrenia at age 20 and their age-matched peers in the general population. At age 40, the investigators found a 17-year discrepancy (Lancet 2009 July 13 [doi:10.1016/S0140-6736(09)60742-X]).

UCSD investigators have looked at more than 1,400 middle-aged and older people with schizophrenia, nearly 80% of whom had prodromal symptoms of the disorder before the age of 40. In longitudinal follow-up with clinical, neuropsychological, and functional evaluations, the investigators found that people with schizophrenia who were adequately treated had a relatively stable course, improvement over time in psychotic symptoms, and a rate of age-related cognitive change similar to that of people without schizophrenia (Acta Psychiatrica Scandinavica 2003;107:336-43).

As would be expected, people with schizophrenia experienced age-related declines in physical health, but they also reported improvements in mental health, as measured by self-rated quality of life, the authors found (Schizophr. Res. 2009;108:207-13).

Predictors of sustained remission include social support, being or having been married, having comparatively greater cognitive and personality reserve, and getting early treatment. However, neither age nor duration of schizophrenia are accurate predictors of successful, sustained remission, Dr. Jeste emphasized.

He cited two of the best-known examples of successful recovery/remission of people who had lived for decades with schizophrenia: John F. Nash, Ph.D., a 1994 winner of the Nobel Prize in Economic Sciences and the subject of the book (and later the film) "A Beautiful Mind" (New York: Simon & Schuster, 1998) and Elyn R. Saks, Ph.D., professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California in Los Angeles. Dr. Saks chronicled her lifelong struggle with psychosis in the memoir "The Center Cannot Hold: My Journey Through Madness" (New York: Hyperion, 2007).

Although they are neither curative nor specific, antipsychotics might help control acute psychotic symptoms and prevent relapse in older patients. However, these drugs do not do much to help with day-to-day function, and carry increased risks of the adverse effects noted earlier. It is important to remember that the Food and Drug Administration issued a public health advisory in 2005 on the treatment of elderly patients with dementia with antipsychotics.

Psychosocial interventions such as cognitive-behavioral therapy and social skills training, functional adaptation training, diabetes awareness, vocational rehabilitation, and other programs also can have significant positive effects on older people with schizophrenia, Dr. Jeste said. The evidence stands in direct contradiction to Freud’s 1924 dictum that "old people are no longer educable," Dr. Jeste noted.

A relatively new treatment approach is mobile intervention, in which smart phones or other communication devices are used to coach patients, promote self-management, and improve their coping skills.

In addition, Dr. Jeste suggested, more studies are needed to see whether the protective benefits of resilience, optimism, and social engagement seen in healthy older adults hold true for people with chronic severe mental illness.

Dr. Jeste reported that he has no financial relationships with the pharmaceutical industry.

NEW YORK – Psychiatrists often project their own ideas about the potential benefits of drugs onto patients without understanding their beliefs about medication, a psychopharmacology specialist said at the American Psychiatric Association’s Institute on Psychiatric Services.

"We call people ‘treatment-resistant’ even if they’re willing to accept all other kinds of treatment: They’re willing to come in and talk to us [and] engage us at therapists," suggested Dr. Ronald J. Diamond, professor of psychiatry at the University of Wisconsin–Madison. "They’re just not willing to take our medication."

Neil Osterweil/IMNG Medical Media

However, by working with patients to better understand their beliefs about medication and recovery goals – whether they want to feel or function better, be able to hold down a job, go to school, or have better relationships – psychiatrists can use medications more effectively to help patients achieve their goals, said Dr. Diamond, who also serves as medical director of the Journey Mental Health Center of Dane County in Madison.

It is useful to consider why patients take medication in light of its inability to cure disease, he said. "Nobody believes that our medications cure bipolar [disorder] or cure schizophrenia," he said. "But that’s OK, because most of our medicines don’t cure diabetes, or chronic obstructive pulmonary disease, or hypertension, either."

Instead, people take medicine to get better, whether that means feeling physically better, having fewer symptoms, improving function, or increasing stability to prevent hospitalization.

The perception of risk from medications also is subjective, however, and a side effect deemed tolerable to the physician might prove unacceptable to the patient, Dr. Diamond said.

For example, he described a long-term patient with schizophrenia who has had a dramatic, sustained response to clozapine. "She has gained more than 100 pounds; she has completely changed her body habitus; and she says with tremendous regret and sadness, ‘I have a really terrible choice: I have choice between being a sane fat lady or a skinny crazy lady.’ "

The message that the physician delivers with the prescription also is critical to success. Telling patients that medications might help them better make decisions about changing their lives or help them to reach their goals, empowers patients and helps them to buy in to their recovery, he said.

Clinicians also need to work with patients to identify specific and concrete targets for medication, with the understanding that some targets might be better indicators of the effect of a medication than others. For example, medication might not have much effect on abnormal beliefs, or cause voices to go away, it but might make the beliefs less intrusive and the voices less distressful. Similarly, suicidal ideation might decrease but not vanish, and a patient’s behavior might improve before he senses a subjective improvement in mood.

"When we talk about what medications are going to do, we should make every medication trial a trial that we and the client agree with: What would getting better mean? What would getting worse mean? How would we know?" he said.

Medication might not work because the patient is not taking it or not taking it for long enough; it’s important that the patient understands that it might take weeks or longer before she feels an effect.

The dose might be too high or too low depending on target symptoms, or other factors might come into play such as comorbid substance abuse, medical illness, or an incorrect diagnosis to explain why a medication may not work.

"Medications do not work for everyone but, in my experience, when somebody says ‘this medication is not helping,’ we immediately assume it’s because of a psychotic loss of insight. Sometimes, the person is right, and sometimes we need to just listen," he said.

Additionally, studies have shown that compliance rates with medication for medical illnesses such as arthritis, diabetes, and hypertension often exceed 50%, and it is safe to assume that the same is true for schizophrenia, Dr. Diamond said.

The key to recovery-oriented prescribing, he emphasized, is to turn the traditional approach to medication on its head. Instead of coming into the treatment room with a diagnosis in hand and coming up with a solution to the diagnosis – medication X – psychiatrists need to start with an understanding of the problem from the patient’s point of view and details of that problem. At that point, it makes sense to come up with a joint medication solution in connection with other solutions for say, social, vocational, educational, or family problems in that patient’s life, Dr. Diamond said.

It’s also vital that the patient has hope of getting better.

"If I look at somebody and what I see is a chronic schizophrenic, then I’m part of the problem," Dr. Diamond said. "But if what I see is someone I could imagine getting a job, getting friends, having more of a life, getting closer to what they want – not that it’s going to happen with every single person – but if I could imagine a possibility in a serious way, then what I’m doing is engendering hope and keeping it alive until that person can carry hope for himself."

Dr. Diamond disclosed a consulting relationship with Novartis, and serving on an editorial board for Janssen Pharmaceutica and a grant committee for Pfizer.

NEW YORK – Psychiatrists often project their own ideas about the potential benefits of drugs onto patients without understanding their beliefs about medication, a psychopharmacology specialist said at the American Psychiatric Association’s Institute on Psychiatric Services.

"We call people ‘treatment-resistant’ even if they’re willing to accept all other kinds of treatment: They’re willing to come in and talk to us [and] engage us at therapists," suggested Dr. Ronald J. Diamond, professor of psychiatry at the University of Wisconsin–Madison. "They’re just not willing to take our medication."

Neil Osterweil/IMNG Medical Media

However, by working with patients to better understand their beliefs about medication and recovery goals – whether they want to feel or function better, be able to hold down a job, go to school, or have better relationships – psychiatrists can use medications more effectively to help patients achieve their goals, said Dr. Diamond, who also serves as medical director of the Journey Mental Health Center of Dane County in Madison.

It is useful to consider why patients take medication in light of its inability to cure disease, he said. "Nobody believes that our medications cure bipolar [disorder] or cure schizophrenia," he said. "But that’s OK, because most of our medicines don’t cure diabetes, or chronic obstructive pulmonary disease, or hypertension, either."

Instead, people take medicine to get better, whether that means feeling physically better, having fewer symptoms, improving function, or increasing stability to prevent hospitalization.

The perception of risk from medications also is subjective, however, and a side effect deemed tolerable to the physician might prove unacceptable to the patient, Dr. Diamond said.

For example, he described a long-term patient with schizophrenia who has had a dramatic, sustained response to clozapine. "She has gained more than 100 pounds; she has completely changed her body habitus; and she says with tremendous regret and sadness, ‘I have a really terrible choice: I have choice between being a sane fat lady or a skinny crazy lady.’ "

The message that the physician delivers with the prescription also is critical to success. Telling patients that medications might help them better make decisions about changing their lives or help them to reach their goals, empowers patients and helps them to buy in to their recovery, he said.

Clinicians also need to work with patients to identify specific and concrete targets for medication, with the understanding that some targets might be better indicators of the effect of a medication than others. For example, medication might not have much effect on abnormal beliefs, or cause voices to go away, it but might make the beliefs less intrusive and the voices less distressful. Similarly, suicidal ideation might decrease but not vanish, and a patient’s behavior might improve before he senses a subjective improvement in mood.

"When we talk about what medications are going to do, we should make every medication trial a trial that we and the client agree with: What would getting better mean? What would getting worse mean? How would we know?" he said.

Medication might not work because the patient is not taking it or not taking it for long enough; it’s important that the patient understands that it might take weeks or longer before she feels an effect.

The dose might be too high or too low depending on target symptoms, or other factors might come into play such as comorbid substance abuse, medical illness, or an incorrect diagnosis to explain why a medication may not work.

"Medications do not work for everyone but, in my experience, when somebody says ‘this medication is not helping,’ we immediately assume it’s because of a psychotic loss of insight. Sometimes, the person is right, and sometimes we need to just listen," he said.

Additionally, studies have shown that compliance rates with medication for medical illnesses such as arthritis, diabetes, and hypertension often exceed 50%, and it is safe to assume that the same is true for schizophrenia, Dr. Diamond said.

The key to recovery-oriented prescribing, he emphasized, is to turn the traditional approach to medication on its head. Instead of coming into the treatment room with a diagnosis in hand and coming up with a solution to the diagnosis – medication X – psychiatrists need to start with an understanding of the problem from the patient’s point of view and details of that problem. At that point, it makes sense to come up with a joint medication solution in connection with other solutions for say, social, vocational, educational, or family problems in that patient’s life, Dr. Diamond said.

It’s also vital that the patient has hope of getting better.

"If I look at somebody and what I see is a chronic schizophrenic, then I’m part of the problem," Dr. Diamond said. "But if what I see is someone I could imagine getting a job, getting friends, having more of a life, getting closer to what they want – not that it’s going to happen with every single person – but if I could imagine a possibility in a serious way, then what I’m doing is engendering hope and keeping it alive until that person can carry hope for himself."

Dr. Diamond disclosed a consulting relationship with Novartis, and serving on an editorial board for Janssen Pharmaceutica and a grant committee for Pfizer.

NEW YORK – Psychiatrists often project their own ideas about the potential benefits of drugs onto patients without understanding their beliefs about medication, a psychopharmacology specialist said at the American Psychiatric Association’s Institute on Psychiatric Services.

"We call people ‘treatment-resistant’ even if they’re willing to accept all other kinds of treatment: They’re willing to come in and talk to us [and] engage us at therapists," suggested Dr. Ronald J. Diamond, professor of psychiatry at the University of Wisconsin–Madison. "They’re just not willing to take our medication."

Neil Osterweil/IMNG Medical Media

However, by working with patients to better understand their beliefs about medication and recovery goals – whether they want to feel or function better, be able to hold down a job, go to school, or have better relationships – psychiatrists can use medications more effectively to help patients achieve their goals, said Dr. Diamond, who also serves as medical director of the Journey Mental Health Center of Dane County in Madison.

It is useful to consider why patients take medication in light of its inability to cure disease, he said. "Nobody believes that our medications cure bipolar [disorder] or cure schizophrenia," he said. "But that’s OK, because most of our medicines don’t cure diabetes, or chronic obstructive pulmonary disease, or hypertension, either."

Instead, people take medicine to get better, whether that means feeling physically better, having fewer symptoms, improving function, or increasing stability to prevent hospitalization.

The perception of risk from medications also is subjective, however, and a side effect deemed tolerable to the physician might prove unacceptable to the patient, Dr. Diamond said.

For example, he described a long-term patient with schizophrenia who has had a dramatic, sustained response to clozapine. "She has gained more than 100 pounds; she has completely changed her body habitus; and she says with tremendous regret and sadness, ‘I have a really terrible choice: I have choice between being a sane fat lady or a skinny crazy lady.’ "

The message that the physician delivers with the prescription also is critical to success. Telling patients that medications might help them better make decisions about changing their lives or help them to reach their goals, empowers patients and helps them to buy in to their recovery, he said.

Clinicians also need to work with patients to identify specific and concrete targets for medication, with the understanding that some targets might be better indicators of the effect of a medication than others. For example, medication might not have much effect on abnormal beliefs, or cause voices to go away, it but might make the beliefs less intrusive and the voices less distressful. Similarly, suicidal ideation might decrease but not vanish, and a patient’s behavior might improve before he senses a subjective improvement in mood.

"When we talk about what medications are going to do, we should make every medication trial a trial that we and the client agree with: What would getting better mean? What would getting worse mean? How would we know?" he said.

Medication might not work because the patient is not taking it or not taking it for long enough; it’s important that the patient understands that it might take weeks or longer before she feels an effect.

The dose might be too high or too low depending on target symptoms, or other factors might come into play such as comorbid substance abuse, medical illness, or an incorrect diagnosis to explain why a medication may not work.

"Medications do not work for everyone but, in my experience, when somebody says ‘this medication is not helping,’ we immediately assume it’s because of a psychotic loss of insight. Sometimes, the person is right, and sometimes we need to just listen," he said.

Additionally, studies have shown that compliance rates with medication for medical illnesses such as arthritis, diabetes, and hypertension often exceed 50%, and it is safe to assume that the same is true for schizophrenia, Dr. Diamond said.

The key to recovery-oriented prescribing, he emphasized, is to turn the traditional approach to medication on its head. Instead of coming into the treatment room with a diagnosis in hand and coming up with a solution to the diagnosis – medication X – psychiatrists need to start with an understanding of the problem from the patient’s point of view and details of that problem. At that point, it makes sense to come up with a joint medication solution in connection with other solutions for say, social, vocational, educational, or family problems in that patient’s life, Dr. Diamond said.

It’s also vital that the patient has hope of getting better.

"If I look at somebody and what I see is a chronic schizophrenic, then I’m part of the problem," Dr. Diamond said. "But if what I see is someone I could imagine getting a job, getting friends, having more of a life, getting closer to what they want – not that it’s going to happen with every single person – but if I could imagine a possibility in a serious way, then what I’m doing is engendering hope and keeping it alive until that person can carry hope for himself."

Dr. Diamond disclosed a consulting relationship with Novartis, and serving on an editorial board for Janssen Pharmaceutica and a grant committee for Pfizer.

NEW YORK – Electronic health records are here to stay, and that’s a good thing for psychiatrists and their patients, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Daniel J. Balog said the benefits of using EHRs are numerous. They are convenient, encourage patient participation in their care, help improve diagnostics and health outcomes, facilitate care coordination, and help large and small practices achieve greater efficiencies and cost savings, said Dr. Balog, a psychiatrist at Andrews Air Force Base in Maryland.

©Brian Jackson/iStockphoto.com

He noted that in a 2008 EHR survey from the Office of the National Coordinator for Health Information Technology, 90% of respondents said that they were satisfied with their systems and that they found it easier to attract and retain staff. In addition, patients seem to buy in to participation in their care.

"Patients equate new technology with quality," Dr. Balog commented.

For providers, EHRs offer quick access to records either on site or remotely, and many systems are equipped with decision-support and performance-improvement tools. EHRs also offer safer prescribing, and eliminate the need for callbacks to clarify an order.

Patients can use their EHRs to collaborate in informed decision making, and the electronic records are essential for two-way communication for managing chronic conditions, he said. EHRs give patients access to full information on their medical evaluation, follow-up information, self-care advice, and reminders, and allow patients and their providers to follow medication levels.

Another advantage to using EHRs is that they can support clinical diagnosis and treatment by giving clinicians complete, accurate, and up-to-date information.

"It makes it easier to identify operational problems within a clinic. Back when there was a paper record, it was more difficult in a systemized way to see what was happening in your own clinics. But here, you can look at different records and see if certain actions are being taken for your patients – an example might be measurements of metabolic status of patients on atypical antipsychotics," Dr. Balog suggested.

Computerized records also can reduce medication errors, and make it easier to check for patient allergies and potential medical cross reactions.

To take some of the economic sting out of converting a records system from paper to pixels, the federal government offers economic incentives that will likely benefit psychiatrists who treat a large number of patients insured by Medicare or Medicaid, said Dr. Robert Plovnick, director of quality and improvement and psychiatric services at the American Psychiatric Association.

Full incentives of up to $18,000 structured as a rebate are available only to those physicians who started participation by Oct. 1, 2012. However, incentives of up to $15,000 are available to those who demonstrate at least 90 consecutive days of meaningful use in 2013, and up to $12,000 for those who get the ball rolling in 2014.

On the other hand, what the feds give they can take away: Starting in 2015, physicians who have not demonstrated implementation and "meaningful use" of a certified EHR system by October 2014 will have Medicare and Medicaid reimbursements reduced by 1%, and the penalties could increase to as much as 5% over time.

Meaningful use of an EHR system would include prescribing electronically, recording patient demographics, documenting smoking status, and providing patients with copies of their records on request, Dr. Plovnick said.

Dr. Lori Simon, a psychiatrist in solo practice in New York City, spent 18 years in software development and implementation in the health industry before becoming a physician.

She advised clinicians to think carefully about what they want an EHR system to do, such as scheduling appointments, billing, clinical charting, order entry, and patient access. Other considerations include how and what data to move into an electronic form. For example, is it better to move all patient records to an electronic form or only those of current patients? Similarly, is it better to move entire charts or subsets of critical data?

Questions that clinicians need to ask include whether the system is certified and qualifies for meaningful use; whether files can be accessed remotely, and if so, how easily; and where the data will be stored, whether on a local or central server or in "the cloud" (that is, a remote server).

In addition, the buyer will need to consider the computer platform (PC or Mac) and whether the software is compatible or can interface with other systems within or outside the institution.

The purchaser should ask the vendor about up-front and continuing costs, what discounts and warranties are available, and what’s included in the package (software, hardware, data conversion services, customization, training, and/or implementation support).

"Solid work before implementation means minimal problems after implementation," she concluded.

Dr. Balog has received royalties from Concept Therapeutics. Dr. Plovnick reported no conflicts of interest. Dr. Simon is on the advisory board of Valant Medical Solutions, maker of an EHR system for psychiatrists.

NEW YORK – Electronic health records are here to stay, and that’s a good thing for psychiatrists and their patients, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Daniel J. Balog said the benefits of using EHRs are numerous. They are convenient, encourage patient participation in their care, help improve diagnostics and health outcomes, facilitate care coordination, and help large and small practices achieve greater efficiencies and cost savings, said Dr. Balog, a psychiatrist at Andrews Air Force Base in Maryland.

©Brian Jackson/iStockphoto.com

He noted that in a 2008 EHR survey from the Office of the National Coordinator for Health Information Technology, 90% of respondents said that they were satisfied with their systems and that they found it easier to attract and retain staff. In addition, patients seem to buy in to participation in their care.

"Patients equate new technology with quality," Dr. Balog commented.

For providers, EHRs offer quick access to records either on site or remotely, and many systems are equipped with decision-support and performance-improvement tools. EHRs also offer safer prescribing, and eliminate the need for callbacks to clarify an order.

Patients can use their EHRs to collaborate in informed decision making, and the electronic records are essential for two-way communication for managing chronic conditions, he said. EHRs give patients access to full information on their medical evaluation, follow-up information, self-care advice, and reminders, and allow patients and their providers to follow medication levels.

Another advantage to using EHRs is that they can support clinical diagnosis and treatment by giving clinicians complete, accurate, and up-to-date information.

"It makes it easier to identify operational problems within a clinic. Back when there was a paper record, it was more difficult in a systemized way to see what was happening in your own clinics. But here, you can look at different records and see if certain actions are being taken for your patients – an example might be measurements of metabolic status of patients on atypical antipsychotics," Dr. Balog suggested.

Computerized records also can reduce medication errors, and make it easier to check for patient allergies and potential medical cross reactions.

To take some of the economic sting out of converting a records system from paper to pixels, the federal government offers economic incentives that will likely benefit psychiatrists who treat a large number of patients insured by Medicare or Medicaid, said Dr. Robert Plovnick, director of quality and improvement and psychiatric services at the American Psychiatric Association.

Full incentives of up to $18,000 structured as a rebate are available only to those physicians who started participation by Oct. 1, 2012. However, incentives of up to $15,000 are available to those who demonstrate at least 90 consecutive days of meaningful use in 2013, and up to $12,000 for those who get the ball rolling in 2014.

On the other hand, what the feds give they can take away: Starting in 2015, physicians who have not demonstrated implementation and "meaningful use" of a certified EHR system by October 2014 will have Medicare and Medicaid reimbursements reduced by 1%, and the penalties could increase to as much as 5% over time.

Meaningful use of an EHR system would include prescribing electronically, recording patient demographics, documenting smoking status, and providing patients with copies of their records on request, Dr. Plovnick said.

Dr. Lori Simon, a psychiatrist in solo practice in New York City, spent 18 years in software development and implementation in the health industry before becoming a physician.

She advised clinicians to think carefully about what they want an EHR system to do, such as scheduling appointments, billing, clinical charting, order entry, and patient access. Other considerations include how and what data to move into an electronic form. For example, is it better to move all patient records to an electronic form or only those of current patients? Similarly, is it better to move entire charts or subsets of critical data?

Questions that clinicians need to ask include whether the system is certified and qualifies for meaningful use; whether files can be accessed remotely, and if so, how easily; and where the data will be stored, whether on a local or central server or in "the cloud" (that is, a remote server).

In addition, the buyer will need to consider the computer platform (PC or Mac) and whether the software is compatible or can interface with other systems within or outside the institution.

The purchaser should ask the vendor about up-front and continuing costs, what discounts and warranties are available, and what’s included in the package (software, hardware, data conversion services, customization, training, and/or implementation support).

"Solid work before implementation means minimal problems after implementation," she concluded.

Dr. Balog has received royalties from Concept Therapeutics. Dr. Plovnick reported no conflicts of interest. Dr. Simon is on the advisory board of Valant Medical Solutions, maker of an EHR system for psychiatrists.

NEW YORK – Electronic health records are here to stay, and that’s a good thing for psychiatrists and their patients, experts said at the American Psychiatric Association’s Institute on Psychiatric Services.

Dr. Daniel J. Balog said the benefits of using EHRs are numerous. They are convenient, encourage patient participation in their care, help improve diagnostics and health outcomes, facilitate care coordination, and help large and small practices achieve greater efficiencies and cost savings, said Dr. Balog, a psychiatrist at Andrews Air Force Base in Maryland.

©Brian Jackson/iStockphoto.com

He noted that in a 2008 EHR survey from the Office of the National Coordinator for Health Information Technology, 90% of respondents said that they were satisfied with their systems and that they found it easier to attract and retain staff. In addition, patients seem to buy in to participation in their care.

"Patients equate new technology with quality," Dr. Balog commented.

For providers, EHRs offer quick access to records either on site or remotely, and many systems are equipped with decision-support and performance-improvement tools. EHRs also offer safer prescribing, and eliminate the need for callbacks to clarify an order.

Patients can use their EHRs to collaborate in informed decision making, and the electronic records are essential for two-way communication for managing chronic conditions, he said. EHRs give patients access to full information on their medical evaluation, follow-up information, self-care advice, and reminders, and allow patients and their providers to follow medication levels.

Another advantage to using EHRs is that they can support clinical diagnosis and treatment by giving clinicians complete, accurate, and up-to-date information.

"It makes it easier to identify operational problems within a clinic. Back when there was a paper record, it was more difficult in a systemized way to see what was happening in your own clinics. But here, you can look at different records and see if certain actions are being taken for your patients – an example might be measurements of metabolic status of patients on atypical antipsychotics," Dr. Balog suggested.

Computerized records also can reduce medication errors, and make it easier to check for patient allergies and potential medical cross reactions.

To take some of the economic sting out of converting a records system from paper to pixels, the federal government offers economic incentives that will likely benefit psychiatrists who treat a large number of patients insured by Medicare or Medicaid, said Dr. Robert Plovnick, director of quality and improvement and psychiatric services at the American Psychiatric Association.

Full incentives of up to $18,000 structured as a rebate are available only to those physicians who started participation by Oct. 1, 2012. However, incentives of up to $15,000 are available to those who demonstrate at least 90 consecutive days of meaningful use in 2013, and up to $12,000 for those who get the ball rolling in 2014.

On the other hand, what the feds give they can take away: Starting in 2015, physicians who have not demonstrated implementation and "meaningful use" of a certified EHR system by October 2014 will have Medicare and Medicaid reimbursements reduced by 1%, and the penalties could increase to as much as 5% over time.

Meaningful use of an EHR system would include prescribing electronically, recording patient demographics, documenting smoking status, and providing patients with copies of their records on request, Dr. Plovnick said.

Dr. Lori Simon, a psychiatrist in solo practice in New York City, spent 18 years in software development and implementation in the health industry before becoming a physician.

She advised clinicians to think carefully about what they want an EHR system to do, such as scheduling appointments, billing, clinical charting, order entry, and patient access. Other considerations include how and what data to move into an electronic form. For example, is it better to move all patient records to an electronic form or only those of current patients? Similarly, is it better to move entire charts or subsets of critical data?

Questions that clinicians need to ask include whether the system is certified and qualifies for meaningful use; whether files can be accessed remotely, and if so, how easily; and where the data will be stored, whether on a local or central server or in "the cloud" (that is, a remote server).

In addition, the buyer will need to consider the computer platform (PC or Mac) and whether the software is compatible or can interface with other systems within or outside the institution.

The purchaser should ask the vendor about up-front and continuing costs, what discounts and warranties are available, and what’s included in the package (software, hardware, data conversion services, customization, training, and/or implementation support).

"Solid work before implementation means minimal problems after implementation," she concluded.

Dr. Balog has received royalties from Concept Therapeutics. Dr. Plovnick reported no conflicts of interest. Dr. Simon is on the advisory board of Valant Medical Solutions, maker of an EHR system for psychiatrists.

NEW YORK – Just as early detection of cancer increases the odds of a favorable outcome, diagnosis and intervention for patients in the early phases of schizophrenia or other primary psychotic disorders might help them to preserve a high level of mental and social function, investigators reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Early results from a small study of adolescents and young adults considered to be at clinical high risk for developing psychosis suggest that a combination of individualized therapies plus group, family, educational, vocational, and social interventions can significantly reduce overall psychotic symptoms, decrease depression and anxiety, and lower patient perceptions of the disruptions that psychosis causes in their lives, said Dr. Michael Birnbaum, a psychiatry resident at Columbia University in New York.

Neil Osterweil/IMNG Medical Media

"Early intervention is based on the idea that mental illness is a progressive pathologic process, that there are very distinct stages, and that each stage requires very specific interventions for that stage," he said.

Psychosis is a clinical manifestation of a progressive pathological process that begins prenatally and progresses until the second or third decade of life when a psychotic episode occurs and a threshold is reached, he said.

The course of schizophrenia moves from the premorbid phase of asymptomatic genetic and environmental vulnerability, to the prodromal phase that might range from generalized, nonspecific symptoms to subthreshold symptoms and mild functional decline, to the first full-threshold psychotic episode with significant functional decline, and finally to remission and relapse.

Early intervention in at-risk patients aims to delay or prevent progression to psychosis and its deleterious effects on social, educational, and occupational functioning. With early treatment, patients might be more engaged and trusting of their therapists, and have a "less risky and traumatic mode of entry into psychiatric care," Dr. Birnbaum said.

Risks High During Critical Period

During the critical period – the first 2-5 years after an initial psychotic episode – an early intervention plan can set the parameters for long-term recovery and outcome. It is during this critical period, Dr. Birnbaum said, that there is the highest risk for disengagement, relapse, and suicide, and the most pronounced functional decline (Schizophr. Bull. 1996;22:201-22).

In this phase, the goals of treatment are management of symptoms through medication, psychosocial interventions aimed at minimizing disability and maximizing functional outcome, reducing stigma, allowing the patient and family to mourn and adapt, and for the clinician to provide the patient with hope.

"We know that reducing the duration of untreated psychosis has a huge impact," he said.

Columbia University has established an early intervention program dubbed PEER, for Prevention, Education, Evaluation, and Rehabilitation. The program is a subspecialty service in which research is translated into clinical practice aimed at early detection and targeted interventions with a multidisciplinary team.

Treatment domains in the program include individualized interventions to help patients recover by exploring personal goals and providing education about the disease and treatments; medication aimed at improving mood and lessening anxiety and symptoms of psychosis, as well as preventing exacerbations; group interventions for improving social skills, decreasing isolation, and reducing stigma; family interventions to promote involvement, reduce stress, and teach crisis management skills; and educational and vocation interventions to help patients achieve their employment goals.

Short-Term Improvements Seen

Dr. Birnbaum and his colleagues conducted a small clinical study of 16 male and 4 female participants in the PEER program. The patients were 12-30 years old, had been diagnosed with a primary psychotic disorder within the last 5 years, and were considered to be at clinical high risk for developing psychosis as identified by the Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms.

Patients were assessed with a wide variety of validated scales for substance abuse, intelligence, disability, and depression and other symptoms.

At baseline, the patients presented with clinically significant anxiety and depression, 70% met criteria for suicide risk, and 23% were considered to be at high risk of suicide. Two-thirds of the sample said their symptoms were disrupting their lives, and more than half reported regular use of alcohol and marijuana.

At 3 months’ follow-up, however, investigators saw significant reductions on the Brief Psychiatric Rating Scale, from a baseline mean of 34.1 to 30.87 (P less than .01), and significant reductions in the rates of depression and anxiety as measured by the Beck Depression Inventory, revision 2, and Self-Report for Childhood Anxiety Related Emotional Disorders (SCARED) rating scales.

In addition, decreases were found in overall symptoms of psychosis, in perceived disruption of school or work (from 75% at baseline to 55% at 3 months), and in disruptions in social life or leisure activities (from 85% to 54.5%). The interventions did not, however, make a difference in use of either alcohol or marijuana.

"It’s hard to draw too many conclusions from this; it’s just preliminary data, but we like to think that joining the PEER program has been helpful, and contributes to decreasing the perceived distress and stabilizing the psychotic symptoms, depression, and anxiety. We’re happy to find out that there’s less disruption, or at least less perceived disruption, in their lives, and we clearly have to focus more on alcohol- and marijuana-focused treatments," said Dr. Birnbaum.

The investigators hope to follow the patients longitudinally to determine what works and what does not, and, ideally, to be able to contribute to future guidelines on intervention in psychosis, he concluded.

Dr. Birnbaum disclosed no relevant conflicts of interest.

NEW YORK – Just as early detection of cancer increases the odds of a favorable outcome, diagnosis and intervention for patients in the early phases of schizophrenia or other primary psychotic disorders might help them to preserve a high level of mental and social function, investigators reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Early results from a small study of adolescents and young adults considered to be at clinical high risk for developing psychosis suggest that a combination of individualized therapies plus group, family, educational, vocational, and social interventions can significantly reduce overall psychotic symptoms, decrease depression and anxiety, and lower patient perceptions of the disruptions that psychosis causes in their lives, said Dr. Michael Birnbaum, a psychiatry resident at Columbia University in New York.

Neil Osterweil/IMNG Medical Media

"Early intervention is based on the idea that mental illness is a progressive pathologic process, that there are very distinct stages, and that each stage requires very specific interventions for that stage," he said.

Psychosis is a clinical manifestation of a progressive pathological process that begins prenatally and progresses until the second or third decade of life when a psychotic episode occurs and a threshold is reached, he said.

The course of schizophrenia moves from the premorbid phase of asymptomatic genetic and environmental vulnerability, to the prodromal phase that might range from generalized, nonspecific symptoms to subthreshold symptoms and mild functional decline, to the first full-threshold psychotic episode with significant functional decline, and finally to remission and relapse.

Early intervention in at-risk patients aims to delay or prevent progression to psychosis and its deleterious effects on social, educational, and occupational functioning. With early treatment, patients might be more engaged and trusting of their therapists, and have a "less risky and traumatic mode of entry into psychiatric care," Dr. Birnbaum said.

Risks High During Critical Period

During the critical period – the first 2-5 years after an initial psychotic episode – an early intervention plan can set the parameters for long-term recovery and outcome. It is during this critical period, Dr. Birnbaum said, that there is the highest risk for disengagement, relapse, and suicide, and the most pronounced functional decline (Schizophr. Bull. 1996;22:201-22).

In this phase, the goals of treatment are management of symptoms through medication, psychosocial interventions aimed at minimizing disability and maximizing functional outcome, reducing stigma, allowing the patient and family to mourn and adapt, and for the clinician to provide the patient with hope.

"We know that reducing the duration of untreated psychosis has a huge impact," he said.

Columbia University has established an early intervention program dubbed PEER, for Prevention, Education, Evaluation, and Rehabilitation. The program is a subspecialty service in which research is translated into clinical practice aimed at early detection and targeted interventions with a multidisciplinary team.

Treatment domains in the program include individualized interventions to help patients recover by exploring personal goals and providing education about the disease and treatments; medication aimed at improving mood and lessening anxiety and symptoms of psychosis, as well as preventing exacerbations; group interventions for improving social skills, decreasing isolation, and reducing stigma; family interventions to promote involvement, reduce stress, and teach crisis management skills; and educational and vocation interventions to help patients achieve their employment goals.

Short-Term Improvements Seen

Dr. Birnbaum and his colleagues conducted a small clinical study of 16 male and 4 female participants in the PEER program. The patients were 12-30 years old, had been diagnosed with a primary psychotic disorder within the last 5 years, and were considered to be at clinical high risk for developing psychosis as identified by the Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms.

Patients were assessed with a wide variety of validated scales for substance abuse, intelligence, disability, and depression and other symptoms.

At baseline, the patients presented with clinically significant anxiety and depression, 70% met criteria for suicide risk, and 23% were considered to be at high risk of suicide. Two-thirds of the sample said their symptoms were disrupting their lives, and more than half reported regular use of alcohol and marijuana.

At 3 months’ follow-up, however, investigators saw significant reductions on the Brief Psychiatric Rating Scale, from a baseline mean of 34.1 to 30.87 (P less than .01), and significant reductions in the rates of depression and anxiety as measured by the Beck Depression Inventory, revision 2, and Self-Report for Childhood Anxiety Related Emotional Disorders (SCARED) rating scales.

In addition, decreases were found in overall symptoms of psychosis, in perceived disruption of school or work (from 75% at baseline to 55% at 3 months), and in disruptions in social life or leisure activities (from 85% to 54.5%). The interventions did not, however, make a difference in use of either alcohol or marijuana.

"It’s hard to draw too many conclusions from this; it’s just preliminary data, but we like to think that joining the PEER program has been helpful, and contributes to decreasing the perceived distress and stabilizing the psychotic symptoms, depression, and anxiety. We’re happy to find out that there’s less disruption, or at least less perceived disruption, in their lives, and we clearly have to focus more on alcohol- and marijuana-focused treatments," said Dr. Birnbaum.

The investigators hope to follow the patients longitudinally to determine what works and what does not, and, ideally, to be able to contribute to future guidelines on intervention in psychosis, he concluded.

Dr. Birnbaum disclosed no relevant conflicts of interest.

NEW YORK – Just as early detection of cancer increases the odds of a favorable outcome, diagnosis and intervention for patients in the early phases of schizophrenia or other primary psychotic disorders might help them to preserve a high level of mental and social function, investigators reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Early results from a small study of adolescents and young adults considered to be at clinical high risk for developing psychosis suggest that a combination of individualized therapies plus group, family, educational, vocational, and social interventions can significantly reduce overall psychotic symptoms, decrease depression and anxiety, and lower patient perceptions of the disruptions that psychosis causes in their lives, said Dr. Michael Birnbaum, a psychiatry resident at Columbia University in New York.

Neil Osterweil/IMNG Medical Media

"Early intervention is based on the idea that mental illness is a progressive pathologic process, that there are very distinct stages, and that each stage requires very specific interventions for that stage," he said.

Psychosis is a clinical manifestation of a progressive pathological process that begins prenatally and progresses until the second or third decade of life when a psychotic episode occurs and a threshold is reached, he said.

The course of schizophrenia moves from the premorbid phase of asymptomatic genetic and environmental vulnerability, to the prodromal phase that might range from generalized, nonspecific symptoms to subthreshold symptoms and mild functional decline, to the first full-threshold psychotic episode with significant functional decline, and finally to remission and relapse.

Early intervention in at-risk patients aims to delay or prevent progression to psychosis and its deleterious effects on social, educational, and occupational functioning. With early treatment, patients might be more engaged and trusting of their therapists, and have a "less risky and traumatic mode of entry into psychiatric care," Dr. Birnbaum said.

Risks High During Critical Period

During the critical period – the first 2-5 years after an initial psychotic episode – an early intervention plan can set the parameters for long-term recovery and outcome. It is during this critical period, Dr. Birnbaum said, that there is the highest risk for disengagement, relapse, and suicide, and the most pronounced functional decline (Schizophr. Bull. 1996;22:201-22).

In this phase, the goals of treatment are management of symptoms through medication, psychosocial interventions aimed at minimizing disability and maximizing functional outcome, reducing stigma, allowing the patient and family to mourn and adapt, and for the clinician to provide the patient with hope.

"We know that reducing the duration of untreated psychosis has a huge impact," he said.

Columbia University has established an early intervention program dubbed PEER, for Prevention, Education, Evaluation, and Rehabilitation. The program is a subspecialty service in which research is translated into clinical practice aimed at early detection and targeted interventions with a multidisciplinary team.

Treatment domains in the program include individualized interventions to help patients recover by exploring personal goals and providing education about the disease and treatments; medication aimed at improving mood and lessening anxiety and symptoms of psychosis, as well as preventing exacerbations; group interventions for improving social skills, decreasing isolation, and reducing stigma; family interventions to promote involvement, reduce stress, and teach crisis management skills; and educational and vocation interventions to help patients achieve their employment goals.

Short-Term Improvements Seen

Dr. Birnbaum and his colleagues conducted a small clinical study of 16 male and 4 female participants in the PEER program. The patients were 12-30 years old, had been diagnosed with a primary psychotic disorder within the last 5 years, and were considered to be at clinical high risk for developing psychosis as identified by the Structured Interview for Prodromal Symptoms and the Scale of Prodromal Symptoms.

Patients were assessed with a wide variety of validated scales for substance abuse, intelligence, disability, and depression and other symptoms.

At baseline, the patients presented with clinically significant anxiety and depression, 70% met criteria for suicide risk, and 23% were considered to be at high risk of suicide. Two-thirds of the sample said their symptoms were disrupting their lives, and more than half reported regular use of alcohol and marijuana.

At 3 months’ follow-up, however, investigators saw significant reductions on the Brief Psychiatric Rating Scale, from a baseline mean of 34.1 to 30.87 (P less than .01), and significant reductions in the rates of depression and anxiety as measured by the Beck Depression Inventory, revision 2, and Self-Report for Childhood Anxiety Related Emotional Disorders (SCARED) rating scales.

In addition, decreases were found in overall symptoms of psychosis, in perceived disruption of school or work (from 75% at baseline to 55% at 3 months), and in disruptions in social life or leisure activities (from 85% to 54.5%). The interventions did not, however, make a difference in use of either alcohol or marijuana.

"It’s hard to draw too many conclusions from this; it’s just preliminary data, but we like to think that joining the PEER program has been helpful, and contributes to decreasing the perceived distress and stabilizing the psychotic symptoms, depression, and anxiety. We’re happy to find out that there’s less disruption, or at least less perceived disruption, in their lives, and we clearly have to focus more on alcohol- and marijuana-focused treatments," said Dr. Birnbaum.

The investigators hope to follow the patients longitudinally to determine what works and what does not, and, ideally, to be able to contribute to future guidelines on intervention in psychosis, he concluded.

Dr. Birnbaum disclosed no relevant conflicts of interest.

NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.

"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.

Neil Osterweil/IMNG Medical Media

The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.

"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.

Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.

Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.

"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.

Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.

At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.

Code of Conduct

Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.

Neil Osterweil/IMNG Medical Media

She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.

Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.

The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.

"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.

The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.

Early Intervention

Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.

Neil Osterweil/IMNG Medical Media

Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.

She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.

Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.

Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.

"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.

"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.

Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.

Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.

Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.

Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.

NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.

"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.

Neil Osterweil/IMNG Medical Media

The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.

"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.

Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.

Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.

"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.

Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.

At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.

Code of Conduct

Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.

Neil Osterweil/IMNG Medical Media

She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.

Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.

The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.

"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.

The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.

Early Intervention

Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.

Neil Osterweil/IMNG Medical Media

Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.

She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.

Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.

Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.

"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.

"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.

Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.

Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.

Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.

Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.

NEW YORK – The adage that physicians are the worst patients has more than a grain of truth to it when it comes to mental health issues, psychiatrists said at a workshop on physician mental health presented at the American Psychiatric Association’s Institute on Psychiatric Services.

"Why is it so hard for doctors to seek help?" asked Dr. Michael Myers, of the department of psychiatry and behavioral sciences at the State University of New York in Brooklyn.

Neil Osterweil/IMNG Medical Media

The stigma of mental illness as perceived by physicians themselves is often a barrier to seeking mental health services. In addition, there is often stigma within the helping professions, and an institutional denial that even physicians might be subject to the thousand natural shocks that other humans are heir to, Dr. Myers said.

"Not all doctors are comfortable looking after other physicians, and it makes them a little squeamish," he said.

Many patients also are ambivalent about being treated by a physician with health issues, making the impaired physician even more leery about getting help, he added.

Stigma reinforces denial and delay in getting help, compounds symptoms, increases refractoriness to treatment, and contributes to strains in personal relationships. Stigma also affects medication adherence, because physicians might think they know better than anyone else what drugs they need.

"Stigma kills," Dr. Myers said, noting that deeply depressed physicians or those who feel very isolated and alienated have increased symptoms of melancholia, guilt, shame, cognitive distortion, and suicidality that can lead to suicidal actions.

Additionally, some physicians with depression or bipolar disorder might have comorbid cocaine, opiate, or alcohol dependence, increasing their risk for death from unintentional overdose or from a cascade of problems associated with substance abuse, such as marital breakups, economic threats to their practices, or scrutiny from medical boards.

At-risk physicians also might hesitate to seek care because they don’t want to impose on others, they have a tendency toward self-reliance, or they are too wrapped up in their work to pay attention to their own needs. Physicians also might worry that breaches in confidentiality could harm their careers, Dr. Myers said.

Code of Conduct

Dr. Linda M. Worley noted that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires accredited facilities to have a code of conduct defining acceptable behavior and specifying which behaviors are disruptive and inappropriate, and to have a process or action plan for managing disruptive staff members.

Neil Osterweil/IMNG Medical Media

She teaches a distressed physicians’ course at Vanderbilt University in Nashville, Tenn., where she is an adjunct clinical professor of medicine. A maximum of six physicians take the 6-month CME course at one time; many are there as condition of their continued employment. There are four faculty members, including a physician, social worker, psychologist, and addiction/assessment counselor. One observer is also allowed for each session, but the rules specify that he or she must take part in the exercises.

Physicians who are referred to the course are first interviewed by telephone to make sure that the program is a good fit and that the participants are not currently substance abusers, and course staff also conduct collateral interviews to determine the mental health needs of prospective participants.

The participants engage in an initial 3-day session at Vanderbilt and have three subsequent 1-day sessions over the ensuing 6 months.

"It’s a transformative learning experience. This is an opportunity to critically reflect on their life events, and that helps them to change their beliefs and their behaviors," Dr. Worley said.

The techniques employed include intellectual didactics, peer group exercises, emotional awareness training, and helping participants identify triggers of their inappropriate behaviors.

Early Intervention

Many of the challenges that Dr. Worley and her colleagues address in experienced physicians also confront physicians in training, noted Dr. Mai-Lan Rogoff, an associate professor of psychiatry and associate dean of student affairs at the University of Massachusetts in Worcester.

Neil Osterweil/IMNG Medical Media

Medical school wellness programs are primarily aimed at preventing burnout, a problem more common among students than alcohol, substance abuse, or suicidality, Dr. Rogoff said.

She defined burnout as a triad of components as measured by the Maslach Burnout Inventory, a rating instrument developed by Christina Maslach, Ph.D., professor of psychology at the University of California at Berkeley.

Burnout is a combination of emotional exhaustion (feelings of being emotionally overextended and exhausted by your work), depersonalization (feelings of being a cog in a machine, having an unfeeling response toward those who receive your services), and having a low sense of personal accomplishment.

Burnout is associated with a variety of negative outcomes, Dr. Rogoff noted, including loss of empathy, substance abuse, and suicidal ideation.

"There are personal and environmental risks for burnout that are known and described in burnout in various settings. The interesting thing is that if you look at medical students and medical school, both sets of risk factors exist there," she said.

"On a personal level, you’ve got perfectionism, low resilience, negative focus, and all those issues, and environmentally one of the risk factors for burnout is unclear or impossible requirements or excessive workloads. This is the way most medical students feel," she added.

Medical students also acutely feel that there is a lack of time and a lack of control over their own circumstances, and that they face major consequences from mistakes and often have to deal with angry, upset, or ungrateful patients.

Medical school wellness programs address both the personal and environmental risk factors for burnout, with an emphasis on the latter. In addition to making counseling and therapy services readily available to students, wellness programs such as that in place at the University of Massachusetts focus on providing students with an increased sense of institutional support and peer support through group and team activities and exercises.

Although there are no objective data showing that such wellness programs work, "there’s absolutely no question that students like these programs," Dr. Rogoff said.

Dr. Myers, Dr. Worley, and Dr. Rogoff all reported having no relevant conflicts of interest.

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.

NEW YORK – Integrating mental health care into primary care settings offers clear benefits for patients and providers. However, careful planning is key to making these models work, clinicians said at the American Psychiatric Association’s Institute on Psychiatric Services.

Among the challenges psychiatrists, social workers, and other mental health clinicians face when trying to merge their services into a primary practice are resistance to collaboration among primary care physicians and other non–mental health clinicians, stigma regarding mental health diagnoses and treatment, communications issues, and the difficulties of treating complex patients, said Dr. Orit Avni-Barron, a psychiatrist at the Gretchen S. and Edward A. Fish Center for Women’s Health at Brigham and Women’s Hospital in Boston.

"When you work with people who are [primary care physicians], dermatologists, or surgeons, they don’t exactly know what mental health [services] can do for them," she said. "They expect things to be fast and to be a certain way, and we need to manage those expectations. In addition, because ours is an outpatient setting, we deal with very medically complex patients who have multiple Axis III diagnoses – a lot of medical issues – in addition to Axis I and Axis II problems," she added.

The five essential elements for effective integration of mental health services are self-definition, interdisciplinary team work, effective communication, limit setting, and education, Dr. Avni-Barron said.

‘Not Hidden in a ... Corner’

Mental health teams must clearly define their role within a practice, said Suzanne Etre, one of two clinical psychiatric social workers at the Fish Center. Given their large staff-to-patient ratio (three MDs and two social workers comprising 2.9 full-time equivalent staff), the mental health staff decided that the only practical approach was to define the service as short term by offering assessments and consultations. Staff physicians perform medical evaluations, recommend medications, and follow patients until they are stable.

Staff social workers help patients with cognitive-behavioral and solution-focused interventions, and also assist with adjustment disorders or bereavement issues. Patients with trauma or more extensive needs for psychiatric services are referred to other providers.

The mental health staff work with primary care physicians within the clinic, share expertise in patient management, and build trust through repeated interactions and scheduled team meetings so that each team member understands the capabilities and limits of the mental health service.

"We try to optimize the value of repeated interaction so that we’re not hidden in a little corner of the practice, and we repeatedly try to build that trust – them with us and us with them. It really helps us to clarify what our roles are," Ms. Etre said.

Setting Limits Key to Success

Primary care practices with a small mental health staff cannot be everything to everyone, and therefore must establish clear limits for both patients and clinicians working in the practices, said Lynn Curran, also a clinical psychiatric social worker at the Fish Center.

Mental health staff members model how to set boundaries and support the ongoing efforts of other clinicians in the practice to maintain them, she said.

The mental health staff members are available for support in situations in which primary care physicians might feel uncomfortable, such as addressing the needs of an urgent care visit patient who appears vaguely suicidal. In such cases, a nurse or primary care physician can have a curbside consult with the mental health clinician on site, or the psychiatric worker might go to the treatment room and role-play the most effective interaction.

The benefits of limit setting, Ms. Curran said, are a reduction in excessive phone calls or patients visits, and an overall reduction in the use of services.

Staff Buy-in Is Essential

At the University of Toronto, this model is called "collaborative care," but the essential goals are the same, said Dr. Diana Kljenak, who is affiliated with the university. She described her experience working to integrate mental health services with six Toronto-area health centers and a hospital-based mental health program. The collaborative arrangement is collectively known as the Toronto Urban Health Alliance (TUHA).

Getting clinical staff and leadership to buy in into the concept is crucial for success. "You can’t do much on your own; you do need leadership support to develop collaborative care," Dr. Kljenak said.

As in Massachusetts, mental health workers in Toronto have to make maximum use of limited resources. Under the TUHA model, mental health staff are colocated in primary care facilities in settings that are familiar to patients and that are not stigmatizing.

Each community health center has a psychiatrist and mental health staffer who provide consultations and services for clients who might not be insured, such as refugees or recent immigrants. Such patients also might not be proficient in English or have a community health center physician.

Psychiatric services are provided on site one-half day each week, and mental health workers are available to health center clinicians for telephone consultations weekdays from 9 a.m. to 5 p.m. Health center clinicians also have 24-hour direct psychiatric emergency services privileges.

"If clinicians want to refer a patient to a psychiatry emergency department, we make sure that they have easy access, [and] that once they get in contact with us and discuss the case with us, they don’t have to wait for hours for medical clearance," Dr. Kljenak said.

All staff members of each community health center receive twice-yearly half-day education in mental health issues identified as being of primary importance to community clinicians.

"Collaborative mental health care is not a fixed model or a specific approach. Its goal is to strengthen the accessibility and delivery of mental health services in primary health settings through interprofessional collaboration, and to provide more coordinated and effective services for individuals with mental health needs," Dr. Kljenak said.

Dr. Avni-Barron, Ms. Etre, Ms. Curran, and Dr. Kljenak reported having no conflicts of interest to disclose.