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Ask patients about sexual function at first visit
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
LAS VEGAS – A brief sexual history should be part of the first patient visit, according to Anita H. Clayton, MD. However, addressing sexual health can prove challenging, especially if the patient is experiencing difficulty in that aspect of life.
“In America, we don’t talk about sex in a serious kind of way,” Dr. Clayton said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “If people are talking about sex they’re either bragging or lying.”
Sexual functioning assessment tools to consider using include the Changes in Sexual Functioning Questionnaire, the Sexual Interest and Desire Inventory for females, and the Decreased Sexual Desire Screener. In premenopausal women, hypoactive sexual desire disorder is a common primary sexual dysfunction. Hypoactive sexual desire disorder is equally common in postmenopausal women, Dr. Clayton said, with the addition of complaints related to vaginal atrophy or genitourinary symptoms of menopause. In men, erectile dysfunction ranks as the most common primary sexual dysfunction. It can occur at any time but tends to increase in frequency at midlife.
Dr. Clayton recommends opening the dialogue with a brief questionnaire or an open-ended question, while maintaining cultural sensitivity, including references to sexual orientation and age. “It can be helpful to define terms,” she added. “I find that people often say, ‘I don’t get aroused anymore,’ but it could possibly mean that they’re not interested in sex anymore. You have to delineate what they’re talking about. Find out if they’re doing the kind of things that previously led them to having a satisfying sexual life. If they’re dissatisfied now, what is the issue? Desire? Arousal?” Taking a ubiquity-style approach to questions also can prove helpful: “Many people with depression experience sexual dysfunction. Do you have any complaints?” Or, “As people get older, sometimes they experience problems in their sexual function or changes in their level of desire. Have you had any such changes?”
The discussion itself might be therapeutic for the patient. “You may find out that what they’re experiencing. It’s not an unusual phenomenon,” said Dr. Clayton, who is a member of the board of directors of the International Society for the Study of Women’s Sexual Health. “For example, if women at midlife are having difficulty with arousal, they might try lubricants. Or, in talking with a younger woman who may not have yet experienced an orgasm, you can tell her it’s not that uncommon and talk about how that can be helped.”
If a sexual problem persists, ask about the nature and duration of the problem and/or changes. Ask about possible stressors and try to rule out any relationship issues or situational problems. “Is the problem generalized or does it occur in all situations? If it’s situational, you probably should work on that first,” said Dr. Clayton, who also has a secondary appointment at the university as professor of clinical obstetrics and gynecology.
Diagnosis of a primary sexual dysfunction is based on clinical presentation, not on testosterone levels or other laboratory values.
Dr. Clayton disclosed having received research grants from several entities, including Forest Research Institute, Janssen, and Takeda Pharmaceuticals. She also has received advisory board fees and/or consulting fees from several companies, including Fabre-Kramer, Takeda, S1 Biopharma, and Sprout Pharmaceuticals, a division of Valeant Pharmaceuticals. Dr. Clayton also has ownership interest in Euthymics Bioscience and S1 Biopharma.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Family-based treatment of anorexia promising
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.
LAS VEGAS – Mounting evidence demonstrates that a family-based approach to treating adolescents with anorexia nervosa usually is more effective than hospitalization.
“In the history of psychiatric literature, families have been blamed a lot for psychiatric problems in their children,” James Lock, MD, PhD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “Parents are put off by anorexia nervosa, because it’s a very confusing illness and terrifying for them to have their children radically change their behavior. These are kids who are often high achieving and have generally been easy to manage: self-starters, self-directors. Then, suddenly, over a period of 6-7 months, they go from being very well to being at death’s door.”
Enter family-based treatment (FBT) for anorexia nervosa, an outpatient intervention appropriate for children and adolescents who are medically stable. Developed around 2001, FBT is designed to restore weight and put the patient’s development back on track. It’s a team approach consisting of a primary therapist, a pediatrician, and a child and adolescent psychiatrist. Brief hospitalization sometimes is used to resolve medical concerns. Dr. Lock, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, described FBT as “a highly focused staged treatment that emphasizes behavioral recovery rather than insight and understanding or cognitive change. This approach might indirectly improve family functioning and reduce eating-related cognitive distortions for the adolescent.”
According to Dr. Lock, coauthor with Daniel Le Grange, PhD, of “Treatment Manual for Anorexia Nervosa: A Family-Based Approach” second edition, (New York: Guilford Press, 2015), the current evidence base for FBT is limited, consisting of 879 patients enrolled in 11 studies at 12 different sites in four countries, as well as one meta-analysis. “We have not done the kind of research in anorexia nervosa that we need to do,” he said. “Parents ask me this every time I sit down with them: ‘Why don’t we know more? Why don’t we have more clinical guidance?’ It’s not been a priority despite the seriousness of this problem [and the] lifelong impact it has.”
Interest in FBT emerged in part because of studies demonstrating the limitations of hospitalizing patients with the disorder. One trial from the United Kingdom found that, among 90 children who were randomized to one of two outpatient treatments, to an inpatient arm, or to no treatment, no differences in outcomes were observed among the treatment groups (Br J Psychiatry. 1991;159:325-33). Similar results were found in a trial of 167 children who were randomized to either inpatient psychiatric treatment or two forms of outpatient management (Br J Psychiatry. 2007;191[5]:427-35). “If you think hospitalization will cure kids with anorexia, this study tells you that isn’t true,” Dr. Lock said. “It doesn’t say that it doesn’t benefit some people. What it says is that, on average, it’s not better than outpatient treatment for adolescents with anorexia nervosa. It’s important to build systems of care around that knowledge.”
Dr. Lock has his own opinion as to why inpatient psychiatric treatment alone usually doesn’t help anorexia nervosa patients in the long-term. “Learning in an inpatient setting is not generalizable,” he said. “You cannot learn and apply the learning that you get in the hospital to your real life: in your family and your school and your social processes. You can dress up psychotherapy any way you want to, but ultimately, it’s about learning. Can parents learn to be effective at helping their children with anorexia nervosa recover?”
In general, FBT is delivered in three phases over the course of 6-12 months. Phase I involves helping parents assume control of weight restoration in their child. “It tries to accomplish at home what could have been accomplished at a hospital by a nursing staff who are trained and able to disrupt and manage destructive behaviors that lead to weight loss and reinforce cognitive distortions,” Dr. Lock said. In phase II, parents gradually hand control over eating back to their child, while phase III involves shifting the family back to discussing adolescent issues without anorexia nervosa at the center of their concern. One fundamental assumption of FBT, he continued, is that it takes an agnostic view as to the cause of anorexia.
“We don’t have to address cause in order to have an effective treatment,” said Dr. Lock, also a professor of pediatrics at the university. “We are going to try to help patients and parents feel valued, not blamed. Secondly, we need to engage parents in a consultative way, recognizing their skills around their family, and help them apply that to anorexia nervosa.” The expected outcome should be a healthy weight, based on the child’s age. According to Dr. Lock, 79% of patients who have gained at least 4 pounds after 4 weeks of FBT will have a favorable treatment response, while 71% of those who don’t meet that benchmark are likely to fail treatment. “The therapeutic alliance is important in treatment outcome, but our studies suggest it is not enough,” he said. “You have to engage people in treatment to get them started, but if you don’t help the parents be effective in promoting weight gain, your therapeutic alliance will diminish.”
In a randomized trial that compared FBT with adolescent-focused individual therapy (AFT) for adolescents with anorexia nervosa, Dr. Lock and his associates found that, at both 6- and 12-month follow-up, FBT was significantly superior to AFT in helping patients achieve full remission, which was defined as normal weight for age and a mean global Eating Disorder Examination score within one standard deviation of published means (Arch Gen Psychiatry. 2010;67[10]:1025-32). A separate trial found that, after FBT was implemented at the Royal Children’s Hospital, Melbourne, admissions decreased by 50%, readmissions decreased by 75%, and the overall number of days patients spent in the hospital fell by 51% (J Pediatr Health Care. 2014 Jul-Aug 28[4]:322-30).
During the first FBT meeting with patients and their families, Dr. Lock discusses the hazards of anorexia nervosa, including the increased risk of death by cardiac arrest and suicide. “I instill the fact that we have a crisis on our hands, and we need to block the development of anorexia nervosa,” he said. “We have no evidence-based treatments for anorexia nervosa once it becomes chronic, and that occurs after about 5 years. The onset is about age 14. At age 19, on average, your chances of complete recovery are greatly diminished. Of course, you can still be of help by supporting improvement in the quality of their lives; you may help improve their thinking and you may help them restore weight, but many will live with the ongoing anorexia nervosa. So, our greatest chance to be effective is early intervention and the window of opportunity is 3-4 years.” Emphasizing these realities “stops people,” he said. “It’s meant to bring them into clear awareness of what they’re facing.”
Dr. Lock disclosed that he has received grant or research support from the National Institute of Mental Health. He also is a consultant for the Training Institute for Child and Adolescent Eating Disorders and has received royalties from Guilford Press and Oxford Press.
Expect tricky journey with BDD patients
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
LAS VEGAS – When working with patients referred for suspected body dysmorphic disorder, expect the initial groundwork to take more time than for other disorders.
“I think that these patients are among the most severely ill that we see in clinical practice – although body dysmorphic disorder often goes unrecognized, because patients are often very ashamed of their concerns, and they find it hard to talk about them,” Katharine A. Phillips, MD, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
Defined in the DSM-5 as preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or that appear slight to others, body dysmorphic disorder (BDD) often causes substantial distress and impairment of day-to-day functioning and is associated with a high rate of suicidality. “When these patients walk into your office, you cannot tell by looking at them what their appearance concern is going to be,” said Dr. Phillips, professor of psychiatry and human behavior at Brown University, Providence, R.I. “Sometimes they point it out to you and you can see that their nostrils are a tiny bit asymmetrical or that they have a little scar on their chin, but it’s not very noticeable. It’s not noticeable until the patient points it out, and even then it’s a slight flaw. But in most cases, the body areas that the patient is preoccupied with look entirely normal.”
BDD affects an estimated 1.7%-2.9% of the general population; about 60% are female. In two-thirds of cases, it onsets during childhood or adolescence. The preoccupations about physical appearance that are associated with the disorder “are very obsessional and distressing,” Dr. Phillips said. “They may think ‘I look ugly. People are laughing at me. I look like a freak.’ They can be focused on any part of their appearance, but most often it’s the face or head. Skin is No. 1, followed by hair and nose.” Complaints may include perceptions of scarring, perceptions of skin color, too much facial hair, or hair that’s too curly or straight. On average, BDD patients report thinking about their perceived flaws for 3-8 hours a day. “Some say it’s all they think about all day long,” said Dr. Phillips, who also directs the Body Dysmorphic Disorder Program at Rhode Island Hospital, in Providence.
“Insight is usually absent or poor, and BDD-related ideas or delusions of reference are common. A majority mistakenly think that other people are taking special notice of them in a negative way because of how they look. If they walk down the street, for example, they may misperceive people as staring at them. If they hear people talking to one another they may think, ‘They must be talking about how ugly my nose is.’ I have patients who have physically assaulted strangers on the street because they’re so certain that they’re being made fun of because of their appearance flaws, which exist in their mind.”
Functional MRI studies of BDD patients demonstrate aberrant visual processing. “They overfocus on tiny details, so the brain is trying to extract detail where there isn’t any,” she explained. “A complementary finding is that they have reduced visual processing of holistic visual stimuli (“seeing the big picture”), compared with healthy controls. One of my patients said to me, ‘When I look at myself I’m just one big pimple without any feet or even any toes.’ They focus in on the body areas they hate and have trouble perceiving the rest of themselves.”
Compulsive repetitive behaviors that are done in response to the appearance preoccupations may include camouflaging (for example, covering perceived hair thinning with a hat), comparing their appearance with that of other people, mirror checking, excessive grooming, questioning others about their appearance or seeking reassurance about the perceived flaws, skin picking, and tanning (often to darken “pale” skin). Functional impairment varies but is usually substantial. For example, in several studies, Dr. Phillips and her associates found that 39% of BDD patients were currently not working because of psychopathology (for most, BDD was their primary diagnosis), about 20% had dropped out of school primarily because of BDD symptoms, 29% had been housebound for at least a week because of their BDD symptoms, 38% had been psychiatrically hospitalized, and the rates of lifetime suicidal ideation ranged from 71% to 81%. “More than one-quarter have attempted suicide,” she said.
About three-quarters seek and two-thirds receive some kind of cosmetic treatment for BDD, most commonly dermatologic treatment and plastic surgery (most often rhinoplasty). “General recommendations are that cosmetic treatment should not be done on these patients,” Dr. Phillips said. A recent practice guideline from the American Academy of Otolaryngology–Head and Neck Surgery recommends that surgeons not operate on a rhinoplasty candidate who screens positive for BDD (Otolaryngol Head Neck Surg. 2017 Feb;156 [2 _suppl]:S1-30).
Serotonin reuptake inhibitors (SRIs) at a high enough dose and for a trial duration of 12-16 weeks are the first-line medications for both nondelusional BDD and delusional BDD. “Most patients with BDD don’t receive adequate first-line pharmacotherapy,” Dr. Phillips said. “Often, high doses of SRIs are needed, sometimes above the [Food and Drug Administration]-approved limits, but I don’t exceed these limits for clomipramine or citalopram.” Recommended SRI doses for BDD are similar to those in the American Psychiatric Association’s practice guideline for obsessive-compulsive disorder. She recommends checking an EKG when patients take a high dose of escitalopram.
In cases of partial or no response to an SRI, consider whether the dose was high enough. “In the vast majority of patients I see for consultation, it wasn’t,” Dr. Phillips said. “Check adherence, and extend the trial if necessary, with 3-4 weeks at the maximum recommended tolerated dose.” In her clinical experience, atypical antipsychotics can sometimes help when added to an SRI, especially in patients who are agitated, aggressive, impulsive, or severely anxious, but antipsychotics are not currently recommended as monotherapy. “In my view, the most pressing need in the BDD field is for research on the efficacy of antipsychotics, especially as SRI augmentation agents,” she said. “We have so little data.” SRI augmentation of buspirone also can prove helpful.
Cognitive-behavioral therapy is the psychosocial treatment of choice for BDD. However, Dr. Phillips cautioned that if BDD patients receive treatment comparable to that of patients with OCD or depression, they probably won’t get better. “It needs to be tailored to BDD symptoms, which are unique in many ways,” she said. “As you would with any patient, express empathy, instill hope, and attend to the therapeutic alliance.”
She recommended using one of the two published evidence-based CBT manuals for BDD: “Cognitive-Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual,” by Sabine Wilhelm, PhD, Dr. Phillips, and Gail Steketee, PhD (New York: Guilford Press, 2013) and “Body Dysmorphic Disorder” by David Veale, MD and Fugen Neziroglu, PhD (West Sussex, U.K.: 2010).
Key CBT principles include helping patients cut down on BDD rituals – for example, by spending less time in front of mirrors or discarding their pocket mirrors. Gradual exposure to social situations, combined with behavioral experiments, also is recommended. Other core CBT components include cognitive therapy, perceptual retraining, motivational interviewing, and providing psychoeducation about BDD.
“I explain to patients that people with BDD see themselves differently than others do, which is supported by visual processing studies,” Dr. Phillips said. “They don’t necessarily buy it, but I think it’s worth putting it out there. Instead of trying to convince them that they look fine, focus on their suffering, preoccupation, and the effect of symptoms on their life. They will usually agree that they are suffering a lot, and that may motivate them for treatment.”
These questions that can help you better understand and diagnose the concerns of BDD patients: “Are you very worried about your appearance in any way?” If yes, “Can you tell me about your concern?”
Suggested questions regarding preoccupations about appearance (DSM-5 criteria A) are: “Does this concern preoccupy you? Do you think about it a lot and wish you could think about it less?” To elicit discussion on the topic of repetitive behaviors (DSM-5 criteria B), consider asking, “Is there anything you feel an urge to do over and over again in response to your appearance concerns?” To determine whether the preoccupations cause clinically significant distress or impairment in functioning (DSM-5 criteria C), ask, “How much does this concern upset you? Does it cause you any problems – socially, in relationships, or with school or work?”
Dr. Phillips disclosed that during the past year, she has received honoraria from the Merck Manual and from Royal Pharma as well as royalties from Oxford University Press, International Creative Management, American Psychiatric Publishing, Guilford Press, and UpToDate.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Risk considerations for suicidal physicians
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
LAS VEGAS – Michael F. Myers, MD, found a common thread in interviews with loved ones, friends, and colleagues of physicians who have taken their own lives: About 10%-15% of the decedents never sought help beforehand.
“They’ve gone from illness to death without any care,” Dr. Myers, a psychiatrist, said at the annual psychopharmacology update held by the Nevada Psychiatric Association.
In a new book based on the interviews, “Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared” (Amazon, 2017), Dr. Myers combined stories from his own clinical practice and qualitative interviews with about 75 men and women to explore reasons why physicians might choose to take their own lives. “Our nonpsychiatric medical colleagues are really anxious to have information from us, because we’re living in an age of burnout; roughly 50% of U.S. physicians suffer from burnout,” he said. In addition to perspectives from bereaved loved ones and former medical colleagues, the book includes insights from others who are affected when doctors die by suicide: their medical training directors, employers, medical students, treating psychiatrists, and patients.
According to the American Foundation for Suicide Prevention, 300-400 physicians take their own lives every year, the equivalent of two to three medical school classes. “That’s a doctor a day we lose to suicide,” said Dr. Myers, a professor of clinical psychiatry at State University of New York, Brooklyn, who specializes in physician health. Compared with the general population, the suicide rate ratio is 2.27 among female physicians and 1.41 among male physicians (Am J Psychiatry. 2004;161[12]:2295-2302), and an estimated 85%-90% of those who carry out a suicide have a psychiatric illness such as major depressive disorder, bipolar disorder, alcohol use and substance use disorder, and borderline personality disorder. Other triggers common to physicians, Dr. Myers said, include other kinds of personality disorders, burnout, untreated anxiety disorders, substance/medication-induced depressive disorder (especially in clinicians who have been self-medicating), and posttraumatic stress disorder.
Additional risk considerations to keep in mind for physician patients include a family history of mood disorders, a sense of professional isolation, coping with lawsuits and/or medical license investigations, previous history of a depressive episode, and a previous suicide attempt. “Sometimes, it’s hard to get this information from a new physician who’s sitting opposite you,” Dr. Myers noted. “We mustn’t forget that there’s a lot of shame, embarrassment, and guilt that’s attached to previous suicide attempts.”
Suicide risk also is elevated for physicians with treatment-refractory psychiatric illness. “It troubles me when a physician is being treated by a generalist, the patient is not doing well, and he or she is not being referred for a second opinion or has never been referred to a psychopharmacologist,” he said. “It’s important that be done, because you know how difficult many of your patients can be. It’s important to have the expertise of a psychopharmacologist. I believe that physician patients will welcome that [second opinion], even if they have to travel 200 miles for it.”
The list of risk considerations for suicidal physicians also includes undiagnosed and untreated bipolar I or II disorder, rapid cycling bipolar disorder, and mixed affective states. “These are important things that can make our patients ill very quickly,” he said. Impulsivity is another consideration, as are severe sleep deprivation, circadian rhythm disturbances, and acute suicidal affective disturbance, which has emerged as a condition to consider in future revisions of DSM-5. “What you see in this condition is an individual becoming suicidal within minutes or hours,” Dr. Myers explained. “It’s usually an agitated state with insomnia and overvalued ideas or delusions that they are completely untreatable and hopeless. Physicians are no different than anyone else in that kind of state.” He emphasized that the stigma attached to mental illness in physicians is pernicious, because untreated mental illness is a key driver of suicide. After one of Dr. Myers’s patients took his own life, his son told Dr. Myers, “My father just hated being a patient. He felt so ashamed. I tried hard, too, but my support wasn’t enough.”
Inadequate treatment can occur for physician patients because of transference and countertransference dynamics “that muddle the treatment dyad,” Dr. Myers added. “We must be mindful of the many issues that are going on when we treat our own.”
In his 2005 book “Why People Die By Suicide,” psychologist Thomas Joiner, PhD, described three key reasons why people choose to take their own lives. The first is “perceived burdensomeness,” or a sense that one is a burden on others. “When I see it in my physician patients, it’s when they have a sense of being a burden on their family and feel they are no longer serving a purpose,” Dr. Myers said. The second reason is “failed belongingness,” or a sense that one does not belong to a valued social group. “This resonates with me,” Dr. Myers said. “Sometimes in therapy sessions, my physician patients will say ‘Don’t call me Dr. Smith anymore; I’m Mr. Smith.’ They’ve removed themselves from the field because they don’t feel like they belong anymore. That’s the unworthiness that physicians can feel.”
The third reason is “learned fearlessness,” or the acquired capability to enact self-injury. Dr. Myers likened it to “the kind of exposure to pain and fear that people also might learn through such experiences as mountain climbing, performing surgery, fighting in wars, or being afflicted with anorexia.”
If you suspect that a physician patient is engaged in suicidal thinking and planning, Dr. Myers advises framing your mental health assessment in the context of trust and mutual respect. “Please don’t be seduced by somebody who’s squeaky clean in the area of suicidality,” he said. “That individual may just not be sharing with you yet. You’re going to have to be firm and parental at times. There’s a lot of terror and shame that can lurk behind those symptomatic behaviors. That’s where you’ll use your expertise. I have found that there are many physicians out there who welcome you to go in that ‘dark place’ with them. For them to be able to share those scary thoughts with someone can enhance the therapeutic alliance.” The inquiry should include questions about potential means and methods, including access to firearms, stockpiled and/or self-prescribed medications, and medications ordered online or stolen/diverted from the workplace. Timely and careful documentation are essential, he said.
The plan for treating suicidal physicians should include obtaining old records and speaking with former treating professionals. “If you get pushback from the patient, say, ‘This is about me wanting to be thorough in my assessment and treatment plan with you,’ ” Dr. Myers said. “There is no substitute for a detailed mental status evaluation, collateral information, clinical intuition, experience, and consultation.” Hospitalizing the physician patient should be judicious and in consultation with others. “If you’re not sure, get a second opinion, because it can be life-saving,” he said, “but if done inappropriately, you can turn them off psychiatry for the rest of their lives. Make sure you’re not just panicking and worrying about some sort of medical-legal risk.”
In cases of split treatment, ensure regular contact with the psychotherapist and document all communication and any changes in status, medication, or psychotherapy modality change.
Dr. Myers cited many ways that psychiatrists can educate their colleagues about burnout, depression, and the risk of suicide. These include offering to give grand rounds or a lecture on the topic, serving on your local CME planning committee, joining your institute’s physician wellness team, serving on your state’s physician health program, and offering to facilitate a group for physicians after a physician colleague has died by suicide. “Postvention is prevention for the next generation,” Dr. Myers said, quoting Edwin S. Shneidman, PhD, founder of the American Association of Suicidology. “By taking care of ourselves and accepting the painful reality of physician suicide, we reach out to those left behind and make a difference. You become a change agent – someone who is part of the movement to stop doctors from killing themselves.”
Dr. Myers disclosed that he has received funding from the Medical Education Speakers Network.
Second-generation antipsychotics effective for stuttering
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
LAS VEGAS – There currently is no Food and Drug Administration–approved medication for the symptomatic treatment of stuttering, but current evidence suggests that second-generation antipsychotics risperidone, olanzapine, and asenapine are beneficial, according to Gerald A. Maguire, MD.
At an annual psychopharmacology update held by the Nevada Psychiatric Association, Dr. Maguire, who is a stutterer himself, said current clinical trials in adults with childhood onset fluency disorder support the dopamine hypothesis of stuttering, where abnormal elevated cerebral dopaminergic activity is implicated.
Older studies found haloperidol to be effective for the treatment of stuttering, but long-term patient outlook is poor because of side effects such as sedation and sexual dysfunction. In a study led by Dr. Maguire, risperidone at a dose of 0.5-2 mg daily for 6 weeks was shown to decrease the percentage of syllables stuttered, time stuttered as a percentage of total time speaking, and overall stuttering severity, compared with placebo (J Clin Psychopharmacol. 2000;20[4]:479-82). A more recent study he also led found that olanzapine at a dose of 2.5-5 mg daily for 90 days showed a significant reduction in symptoms as measured by multiple tools, including the Stuttering Severity Instrument–Third Edition, the Clinical Global Impression scale, and the subject-rated self-assessment of stuttering scale (Ann Clin Psychiatry. 2004;16[2]:63-7).
Dr. Maguire, also associate dean of graduate medical education at the University of California, Riverside medical school, added that findings from several case reports suggest that asenapine and aripiprazole also are effective for managing stuttering symptoms. “Further studies of these drugs are warranted given better side-effect profiles as compared to other second-generation antipsychotics,” he said. There are ongoing investigations of other medications for the treatment of stuttering, including ecopipam, a D-1 dopamine receptor antagonist. An open-label study of ecopipam in adults who stutter is currently under way.
Dr. Maguire disclosed that he has received grant or research support from Intracellular, the Stanley Foundation, and Sunovion. He also is a consultant for Lundbeck, Otsuka, Sunovion, Takeda, and is a member of the speakers’ bureau or has received honoraria from Acadia, Lundbeck, Otsuka, Sunovion, Takeda, and Vanda.
AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Treating psychopathology in developmentally disabled tricky
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
LAS VEGAS – Individuals with intellectual disability experience behavioral and psychiatric illness at higher rates than the general population, according to Bryan H. King, MD.
“Increasingly, these individuals are showing up in all of our clinical practices,” Dr. King said at an annual psychopharmacology update held by the Nevada Psychiatric Association. “In this area, it’s not so much that the population doesn’t experience psychiatric illness, but the diagnosis can be challenging because the presentation of symptoms may be different. For someone who can’t articulate whether they’re feeling anxious, fearful, or nervous, it’s more challenging to make a diagnosis.”
More than 10 years ago, researchers from the University of North Carolina at Chapel Hill compared health disparities between adults with developmental disabilities in North Carolina and adults in the state with other disabilities and adults without disabilities (Public Health Rep. 2004;114[4]:418-26). They found those in the developmental disability group had a similar or greater risk of having high blood pressure, cardiovascular disease, diabetes, and chronic pain, compared with nondisabled adults. In addition, 24% of adults in the developmental disability group reported having either no one to talk to about personal things or often felt lonely.
A more recent, large national study found that, compared with adults with no autism diagnoses, those diagnosed with autism had significantly increased rates for all psychiatric disorders, including depression, anxiety, bipolar disorder, obsessive-compulsive disorder, schizophrenia (a more than 20-fold increased rate), and suicide attempts (Autism. 2015;19[7]:814-23). In addition, nearly all medical conditions such as obesity and dyslipidemia were significantly more common in adults with autism.
Results from a separate study of 371 adults with intellectual disabilities found that 40% had at least one mental health disorder and 45% had at least one moderate or severe behavior problem (Soc Psychiatry Psychiatr Epidemiol. 2016;51:767-76). In addition, the highest ratios of unmet to met need were found with respect to sexuality issues and with respect to mental health problems.
Once a diagnosis is made, Dr. King said patients who have developmental disabilities should be treated in the same way as patients who do not. “There is a tremendous amount of heterogeneity in this population,” he said. “If you are confident that you have someone before you who has depression, the treatment for depression is going to proceed in the same ways it does for someone without the condition. Let that guide the way for medications you are going to use.”
In a recent edition of Current Opinion in Psychiatry, authors Na Young Ji, MD, and Robert L. Findling, MD, reviewed current evidence-based pharmacotherapy options for mental health problems in people with intellectual disability (Curr Opin Psychiatry. 2016;29:103-25). Their five key points were:
1. “Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors associated with intellectual disability.
2. “For attention-deficit/hyperactivity disorder symptoms, methylphenidate has been shown to be effective, and atomoxetine and alpha-agonists might be beneficial.
3. “Lithium might be effective in reducing aggression. Evidence for the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors is insufficient to draw conclusions.
4. “Antidepressants are often poorly tolerated and do not appear to be effective in decreasing repetitive or stereotypic behaviors associated with intellectual disability.
5. “Melatonin appears to improve sleep in people with intellectual disability.”
Dr. King noted that the data for using lithium in people with intellectual disability “are very old. There’s been nothing recent to help us fine-tune the indications.” He said naltrexone is among the best studied in this population, “especially for self-injurious behavior. The two large placebo-controlled trials were negative. In my own clinical experience, I have not seen it helpful.”
Dr. King disclosed that he has received research funding from the National Institutes of Health, Janssen, and Roche. He also is a consultant for Care Management Technologies and Neurotrope.
EXPERT ANALYSIS AT THE NPA PSYCHOPHARMACOLOGY UPDATE
Hope on the horizon for novel antidepressants
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
LAS VEGAS – There remains a great unmet need for more effective and rapidly acting treatments for major depressive disorder, and research is revealing that both new and existing drugs may help, according to one expert.
One argument for additional treatment options is the current rate of suicide in the United States, which ranks as the 10th leading cause of death among persons aged 10 years and older, Gerard Sanacora, MD, PhD, said at an annual psychopharmacology update held by the Nevada Psychiatric Association. Another argument for new antidepressants stems from the results of the STAR*D trial, which found that 37% of patients with major depressive disorder who were treated with citalopram monotherapy had remission with the first treatment.
Dr. Sanacora, who is also director of the Yale Depression Research Program, said that there is a reconceptualization of how clinicians think about the pathophysiology of depression and the path to novel treatment development. A variety of novel pharmacologic and somatic treatments, with new mechanisms of action, are currently undergoing validation for treatment-resistant depression. These include glutamatergic, GABAergic, opioid, and anti‐inflammatory drugs.
Drugs that modulate GABAergic and glutamatergic neurotransmission have anxiolytic and antidepressant activities in rodent models of depression. In addition, the robust, rapid, and relatively sustained antidepressant effects of low-dose ketamine have been observed in double-blind placebo crossover trials in patients with treatment-resistant major depression (Biol Psych. 2000 Feb 15;47[4]:351-4 and Arch Gen Psych. 2006 Aug;63[8]:856-64). Currently, Dr. Sanacora said, more than 80 clinics in the United States provide ketamine therapy, yet clinicians face balancing the potential benefits of the drug with inherent limitations of the ketamine studies to date. These include the fact that the study drug blinding is ineffective; the optimal dose, route, or frequency has not been determined; the duration of effect is unknown; the long-term effectiveness and safety are unclear; and the moderators and mediators of response are unknown.
Results from a National Institutes of Mental Health–funded double-blind, placebo-controlled study examining various doses of ketamine in treatment-resistant depression are anticipated sometime this year. In 2013, a trial sponsored by Janssen Research & Development titled a Study to Evaluate the Safety and Efficacy of Intranasal Esketamine in Treatment-Resistant Depression (SYNAPSE) set out to assess the efficacy and dose response of intranasal esketamine (panel A: 28 mg, 56 mg, and 84 mg; panel B: 14 mg and 56 mg), compared with placebo, in improving depressive symptoms in participants with treatment-resistant depression. The researchers found a positive effect of esketamine vs. saline placebo with some evidence of a dose-response curve, suggesting higher doses to be more effective. Some published studies suggest that chronic ketamine use causes impairments in working memory and other cognitive effects (Addiction. 2009 Jan;104[1]:77-87 and Front Psych. 2014 Dec 4;5:149), while others have found that ketamine does not cause memory deficits when given on up to six occasions (Int J Neuropsychopharmacol. 2014 Jun 25;17[11]:1805-13 and J Psychopharmacol. 2014 Apr 3;28[6]:536-44).
Another drug being studied for major depressive disorder is the investigational agent SAGE-547, an allosteric neurosteroid modulator of both synaptic and extrasynaptic GABA receptors. Preliminary results from a double-blind, placebo-controlled phase II trial in 21 patients with postpartum depression showed that the Hamilton Rating Scale for Depression (HAM-D) total score was reduced by SAGE-547, compared with placebo, at 60 hours (P = .008).
Buprenorphine, a partial mu opioid agonist commonly used in addiction treatment, may also play a future role in helping patients with treatment-resistant depression. One randomized study of 88 patients found that those who took very low doses of buprenorphine for 2 or 4 weeks had significantly lower scores on the Beck Suicide Ideation Scale, compared with their counterparts on placebo (Am J Psychiatry. 2016 May 1;173[5]491-8).
Drugs with anti-inflammatory properties may also have a role. One study of 60 patients found that the tumor necrosis factor–alpha antagonist infliximab may benefit patients with treatment-resistant depression who have high inflammatory biomarkers at baseline (JAMA Psychiatry. 2013 Jan;70[1]:31-41).
“Active participation in clinical research efforts is critical to the advancement of future treatment approaches,” he said.
Dr. Sanacora disclosed having received consulting fees and/or research agreements from numerous industry sources. In addition, free medication was provided to Dr. Sanacora by sanofi‐aventis for a study sponsored by the National Institutes of Health.
EXPERT ANALYSIS FROM THE NPA PSYCHOPHARMACOLOGY UPDATE