We climbed concrete ramps from the subway’s

and my first vision of heaven, Ebbets Field,

Brooklyn    Dodgers, the summer of ‘54,

my father buying hotdogs, my grandfathers

chomping Cuban cigars. And Oh! the high arc

of long fly balls, and Oh! the crowd’s roar,

the scoreboard lit with incandescent bulbs,

the hands of the Longines clock marking time,

vendors shouting, “Beeeaah heeeah,” the smells

of    smoke and piss and peanuts, the Bums

winning a thriller in the bottom of the ninth,

ushers opening    the gates to the field,

my small steps taking me all the way home.

or my grandfathers, bent over and whispered,

“Step on home plate, kid, and pray the Dodgers

stay.”    And with all the energy my tiny

soul could summon, I jumped and prayed and landed

on home plate, still young enough to believe

all the men I loved would never leave me.

Articles

We climbed concrete ramps from the subway’s underground world, up to the grandstand and my first vision of heaven...

Prayer

It has been 6 weeks since my first sweet tea. Having traveled a good bit of the country, I would have thought I’d tasted most of what’s out there by now, but I was wrong. My first taste of sweet tea was a jolt, all at once familiar yet unexpected-much like my Southern experience so far.

Six weeks ago, my wife and I began the process of moving our life, 3 kids in tow, to Charlotte, North Carolina, from Connecticut, where I worked in the trenches of public psychiatry, doing my bit to improve access and care for those with mental illness. These things never go smoothly, but I had a good rhythm going in an outstanding agency and had great colleagues and patients. I even saw significant forward momentum.

What drew us to the South was an opportunity to be part of a much larger health care system that is poised on the leading edge of reform, including, remarkably, placing mental health front and center. Here, like everywhere else, patients are falling through the cracks, backing up in emergency departments, boarding in observation beds-or worse. Too often the severely mentally ill are caught up in the criminal justice system rather than receiving the medical treatment they deserve. Stable mental health should be no more optional than good cardiac care, but there are significant factors that conspire to keep that from happening. Stigma is one factor; cost is another and two others loom large: the current shortage of psychiatrists and other trained providers, and lack of coordination among caregivers.

Carolinas HealthCare System has quietly become the second largest non-profit health care system in the US, with 40 hospitals and 800 care locations in 2 states. If I thought the tea here in the South was a jolt, this large system is really shaking things up with an ambitious goal to lead health care transformation. Zeev Neuwirth, MD, Senior VP and Chief Medical Officer of Ambulatory Care and Corporate Health Services, speaks to this vision when he says, “The current trajectory of US health care costs is unsustainable and the increasingly complex needs of patients shouldered solely by the primary care physician is anachronistic. We need to shift the paradigm from providing episodic, fragmented care to an integrated, team-based, coordinated system that addresses the physical as well as psychosocial needs of patients across the continuum of their health care experience. Behavioral health care is an integral component of any such high-quality integrated delivery network.”

Carolinas HealthCare System is creating an integrated service line for behavioral health across the system, and I am here to help that hap-pen. We have invested millions of dollars in virtual technology in order to bring psychiatry into hundreds of our primary care offices. For example, we’re installing virtual technology that allows primary care providers to consult with a psychiatrist via computer teleconference. This innovation alone will allow a single psychiatrist to serve many more patients. It will also add collegial support to primary care providers, augmenting their skills and raising their awareness of mental health issues while ensuring better patient outcomes.

The sad irony is that we have good tools to treat mental disorders successfully but less than half of those with mental illness get any treatment at all. Those who do are often forced to navigate a tangled maze that leaves them confused and feel-ing even more like outsiders. The truly integrated system we are planning here in Charlotte means that providers across all medical disciplines will gain a better understanding of how mental health affects their patients and, ultimately, the fiscal bottom line.

In April 2013, we broke ground for a new 66-bed psychiatric hospital. We’re building this hospital without state dollars . . . and without immediate plans to turn a profit. We’re doing it because it’s the right thing to do. This hospital is part of a vast new infrastructure that positions behavioral health as an integral part of a complete health care system. As grand as this plan is, it is historically consistent with Carolinas HealthCare System’s commitment to offer quality care to everyone-regardless of age, race, or financial or demographic status. One of every 4 people needs mental health care at some time in his or her life. If we ignore this need, the shock wave that results upsets the entire health care system. We’re betting that our investment in excellent behavioral health care throughout a large system will make good fiscal sense in the long run, particularly in a value- and outcome-based environment.

 have) waited until I’d fully acclimated to shout about this. The work of health care reform is daunting no matter where you are. But like the tea, there are unexpected surprises here in Charlotte. The first one came during my orientation program to this giant organization. Along with a hundred other new hires, I packed bags for hungry kids with donated food. Later I was in a breakout group focused on the company pillar of humility. Humility is generally a good thing in health care systems, but in mental health care-where our most corrosive villain is stigma-humility may be more valuable than gold. At my orientation, I saw Carolinas HealthCare System’s dedication to its patients firsthand. Clearly the change that is happening here will not be “top down” but instead driven by the needs of the community.

Across our nation, mental health care funding and resources are either slashed to the bone or nonexistent. Yet, at the same time, there is a unique opportunity available right now for any and all who want to tackle reform. Driven by national tragedies and the unsustainable nature of the current system, the American public is talking about mental health like we haven’t since the 1960s. Carolinas HealthCare System is not the only organization building a hospital and committing major resources to mental health care, but it is one of the precious few. To all those who are contemplating investment and doubling down on the bet that excellent mental health care will drive the bottom line, who want to turn the prevailing national story of the lack of resources and the steady drumbeat of hospital bed closures on its head, I say the news from Charlotte is like a refreshing jolt of sweet tea.

Across our nation, mental health care funding and resources are either slashed to the bone or nonexistent. Yet, at the same time, there is a unique opportunity available right now for any and all who want to tackle reform.

Sweet Tea and Mental Health Transformation

Quick . . . name a class of prescription medications that, by most evidence, appears to be overprescribed and abused and the use of which has resulted in an increasing number of emergency department visits.

If you said “opioids,” you would be right. This is probably the answer most health care professionals would give. However, there is another response that is given much less frequently but would be equally true: benzodiazepines.

I wish I could say that this inattention to benzodiazepines is something new, but my personal experience indicates it is not. Twenty years ago, I coauthored one of the first papers that examined the use of benzodiazepines by patients with chronic pain and found that these agents were overprescribed.

 With rare exception since that time, the lectures I have attended on overprescription of medications have focused on opioids. When I have raised the issue of overuse of benzodiazepines, the speakers have either responded that they were unaware of any problem or offered the odd response that the audiences were interested in opioids, not benzodiazepines.

Two reports from the CDC indicate the scope of the problem with benzodiazepines. From 2004 to 2008, there was a 111% increase (going from 144,600 to 305,900) in the estimated number of emergency department visits involving nonmedical use of opioid analgesics.

 For the same period, there was an 89% increase (from 143,500 to 271,700) in such visits for benzodiazepines. Data from the National Vital Statistics System multiple cause-of-death file from 2010 show that opioid analgesics were involved in 75% of pharmaceutical overdose deaths; benzodiazepines were in second place, with involvement in 29% of such deaths.

 Benzodiazepines were also involved in 30% of opioid-related deaths-far more than any other class of drugs. This indicates that combining benzodiazepines and opioids may be especially dangerous.

Of course, patients who use prescription drugs for nonmedical purposes may be purchasing drugs illicitly, so it is difficult to determine how many of those in the CDC studies may have had prescriptions written for them by physicians. However, 2 studies on opioid prescriptions in the Department of Veterans Affairs health care system indicate that benzodiazepines continue to be frequently prescribed for patients with chronic pain.

In the first study, the authors found that 32% of patients taking what they defined as high doses of opioid analgesics for chronic noncancer pain and 25% of those taking what was considered a traditional dose of opioids for the pain were also taking a benzodiazepine.

In contrast, only 10% of patients who were not receiving an opioid were given a prescription for a benzodiazepine.

The second study involved patients receiving methadone or a long-acting form of morphine for chronic pain. In this study, at least 28 days of a benzodiazepine had also been prescribed for 26% of the patients at the same time as they were taking the opioid.

Concerns about benzodiazepine use by patients with chronic pain

 the use of benzodiazepines by patients with chronic pain was generally contraindicated. Since that time, additional studies have only strengthened this premise-most notably research indicating that benzodiazepines reduce the analgesic effects of opioids and that their long-term use can result in hyperalgesia, thereby exacerbating the pain by lowering the pain threshhold.

There are the additional problems well known to psychiatrists. Benzodiazepines can be addictive. In fact, from my experience, it is often more difficult to discontinue benzodiazepines than opioids. Many times after patients have told me that they are willing to do anything to reduce their pain and I have recommended trying to discontinue benzodiazepine use, they have modified their responses to “anything but that!”

Although benzodiazepines can be effective for the treatment of anxiety for short periods, they are, with rare exceptions, not generally indicated for chronic anxiety in the absence of a diagnosable anxiety disorder. However, few of the patients with chronic pain that I have seen during my career have had a diagnosis of an anxiety disorder at any time while receiving these medications. Furthermore, many of those who have anxiety also have associated depression, which may be exacerbated by the benzodiazepines. Obviously, treatment with an antidepressant would be a far better choice for these patients-especially in light of the fact that SNRIs can provide marked analgesia in addition to their antidepressant and anxiolytic benefits. Even for medication management of brief periods of anxiety, buspirone may be a better choice.

Benzodiazepines have been and continue to be frequently used for the treatment of insomnia. In fact, this was the most common reason why the patients in my study were taking benzodiazepines.

 Studies of patients with chronic pain who had difficulty in sleeping show that benzodiazepines interfere with the same stages of sleep most likely to be problematic. The patients I studied found that the benzodiazepines provided little benefit for improving sleep. With the availability of the non-benzodiazepine sedative hypnotics, including zolpidem, zaleplon, and eszopiclone, there is now little rea-son for benzodiazepines to be used to aid sleep.

Benzodiazepines are also frequently employed as muscle relaxants, but there is limited literature to support this. Whether they provide much direct muscle relaxation or whether their benefits are primarily related to their sedating effects is open to question. There are better choices if a muscle relaxant is indicated, such as cyclobenzaprine and tizanidine, which do not carry the potential problems that are associated with benzodiazepines.

Although there has been a growing focus on the abuse of opioid analgesics, with the development of tamper-resistant formulations and the requirement that physicians take risk evaluation and mitigation strategy (REMS) programs to prescribe certain opioids, benzodiazepines have not received similar attention.

There is no doubt that abuse of opioid analagesics is a major problem that needs to be addressed. But ignoring problems associated with benzodiazepine use is injurious to the nation’s public health.

 Governale L. Outpatient prescription opioid utilization in the US, years 2000-2009. July 22, 2010. http://
www.fda.gov/downloads/AdvisoryCommitteesMeetingMaterials/Drugs/AnestheticandLifeSupportDrugsAdvisoryCommittee/ucm220950.pdf. Accessed May 20, 2013.

 Centers for Disease Control and Prevention. Primary Care and Public Health Initiative. Balancing pain management and prescription opioid abuse: educational module. October 24, 2012. http://www.cdc.gov/primarycare/materials/opioidabuse. Accessed May 20, 2013.

 Centers for Disease Control and Prevention. Suicide among adults aged 35-64-United States, 1999-2010. 

 Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. 

 Ilgen MA, Zivin K, Austin KL, et al. Severe pain predicts greater likelihood of subsequent suicide. 

 Pereira A, Gitlin MJ, Gross RA, et al. Suicidality associated with antiepileptic drugs: implications for the treatment of neuropathic pain and fibromyalgia. 

Quick . . . name a class of prescription medications that, by most evidence, appears to be overprescribed and abused and the use of which has resulted in an increasing number of emergency department visits. If you said "opioids," you would be right.

Benzodiazepines and Pain

Which of the following complementary and alternative medicine (CAM) therapies may have beneficial effects on symptoms of mild cognitive impairment (MCI) and Alzheimer disease (AD)? Integrative psychiatry specialist, James Lake, MD, answers this question and discusses the latest research in this Q&A. Take the quiz and test your knowledge.



For the answer and discussion, please click here



The above-mentioned CAM therapies may reduce symptoms of MCI and AD.

Select CAM therapies may lessen symptoms of cognitive impairment related to AD, stroke, traumatic brain injury (TBI), and normal aging.

Dietary changes that are correlated with a reduced risk of AD include restricted intake of saturated fats and moderate wine consumption. Regular aerobic exercise may also reduce the risk of any kind of dementia. There is evidence that Ginkgo biloba is an effective treatment of moderate cognitive impairment in early AD and vascular dementia.

 Phosphatidylserine and huperzine A are other natural products that will probably play increasingly important roles as adjunctive agents or stand-alone treatments in early or moderate AD, MCI, and age-related cognitive decline.

In addition, cytidinediphosphocholine (CDP-choline) holds promise as a treatment of cognitive impairment following stroke or TBI. The essential oils of lemon balm and common sage reduce agitation and nighttime anxiety (eg, “sundowning”) in individuals with dementia when applied to the arms and face.

Regular music therapy may yield transient improvements in agitated behavior and cognitive functioning in patients with AD. Research findings suggest that regular Healing Touch

 may have beneficial calming effects and improve global functioning in AD.

Which of the following complementary and alternative medicine (CAM) therapies may have beneficial effects on symptoms of mild cognitive impairment (MCI) and Alzheimer disease (AD)?

Benefits of CAM Therapies for Dementia

Most psychiatrists are trained to diagnose symptoms and treat patients with medication, psychotherapy, or a combination of both. Unfortunately, while we may have an appreciation of family, social, and cultural contexts, the understanding of these factors are not our strong suit. As physicians, we are focused on disease states and, unfortunately, are less familiar with issues of resiliency and strength- or asset-based approaches to patient care. In addition, we are less familiar with how protective factors minimize the impact of traumatic experiences.

Psychiatrists need to understand how living in violent families and neighborhoods increases the likelihood of trauma and the psychiatric sequelae associated with it as well as how to respond in the aftermath.



Prevalence of exposure to trauma and violence



Because interpersonal violence is a major problem in the African American community, it is not surprising that children are frequently exposed to violence in their homes and in their communities.

 Several epidemiological studies have shown a high prevalence of exposure to trauma in a variety of cultural, racial, and ethnic groups as well in various socioeconomic classes.

 In addition, because the contexts of epidemiological studies are often radically different, my colleagues and I have always thought it was a good idea to study patients in our clinical practice.

Of the 330 patients currently being seen for medication monitoring at the Community Mental Health Council, 18 (5.5%) have extensive histories of childhood trauma.

 Our center provides mental health services to both high– and low–collective efficacy communities; it is clear that there are either higher rates of trauma in the low–collective efficacy community and/or there are fewer protective factors in that type of community.

 Compared with patients from the high–collective efficacy community, those from the low–collective efficacy community are more likely to have been exposed to violence, either as victim or as witness-or both.

Not only are members of communities that have low collective efficacy more likely to see violence, but also families that are isolated and that lack access to social supports are more likely to be under stress and the children to be traumatized. Trauma has the potential to result in a variety of psychiatric sequelae no matter where it comes from-the family or the community. Accordingly, clinical psychiatrists need to be facile in talking to patients about childhood trauma during the initial psychiatric evaluation.

What new information does this article provide?


? The article places a great deal of emphasis of getting a trauma history from all patients and reminds us of the victimization questions that were developed by Jacobson and Bell/Jenkins. Advice is provided on how to help persons who have been traumatized-by treating them as people, not as neurochemical machines.

What are the implications for psychiatric practice?


? The information provided will help psychiatrists to be more responsive to issues of childhood trauma in adult patients. Although not all persons who experience childhood trauma automatically have a stress disorder as an adult, it is still important to include questions about childhood trauma when obtaining a history of an adult patient with a stress disorder.

Exploring childhood trauma in the initial psychiatric evaluation

Considering the prevalence of childhood and adult trauma, initial psychiatric evaluations should include a history of childhood and adult trauma but should take no longer than 30 minutes. Our experience is that childhood trauma histories are especially important in middle-aged women who have an early history of substance abuse or who present with generalized anxiety, panic attacks, and symptoms of depression.

The 30-minute investigation may need to be adjusted depending on the patient’s ability to relate his or her childhood and adult traumatic experiences (

). Wise and well-trained psychiatrists do not open “Pandora’s box” without knowing they can close it before the session is over, so the patient’s tolerance for these questions needs to be carefully gauged. You can always delve deeper in a future session-my experience is that the majority of patients tolerate these questions well and are relieved to finally meet someone who has enough compassion and courage to ask the questions in an empathetic manner.

A 51-year-old black woman has been taking multiple medications for depression, panic attacks, and anxiety for approximately 10 years. She has episodes of depression, but they never last longer than a few days and, thus, are not persistent enough to warrant a diagnosis of MDD. Before the onset of symptoms, she had a fairly decent life. She completed her requirements for a high school diploma and had many years of working in various blue-collar jobs. However, she has never really been happy, and in her mid-20s, she had an 8-year stint of cocaine use.

When asked about the cocaine use, she brushed the question aside, briefly stating that she had gotten into a “bad situation” early in her life. At that point, she was directly asked about exposure to childhood trauma (sexual assault, physical assault, witnessing violence) because it was the examiner’s experience that patients with her symptom pattern frequently had experiences with trauma as children. Only then did she report that her fifth grade teacher had sexually abused her the entire year she was in his class. She never told anyone, not even her mother. In addition, she reported several episodes of rape when she was using drugs.

She mused that she had always felt this was at the root of her problem but had never felt comfortable discussing it. She could not believe that something that had happened so long in the past could be affecting her life so many years later. On further reflection, she wondered whether this early childhood trauma had resulted in her lack of self-esteem, which caused her to sleep around when she was younger; whether her need to numb herself to the chronic memories of her abuse (that still haunted her) had resulted in her drug use; or whether this was the reason she was so overprotective of her 3 daughters when they were growing up.


Proposed criteria for developmental trauma disorder

During the 30-minute evaluation, we explained that she has been repeatedly traumatized and that the trauma had taken its toll on her. A psychiatric assessment indicates that she suffers from developmental trauma disorder (

 She was given a copy of the criteria to help her better understand the course her life had taken. In addition, we proposed that she shift her “learned helplessness” into “learned helpfulness.” This perspective will put her into a position of not letting the traumatic experiences define her.

 And it will give her a sense of mastery and allow her to develop a sense of power over the bad experiences.

She was also told about the Gift From Within Web site

 that she could use as a resource for further information. The patient was extraordinarily grateful for her new understanding of her problems. Lastly, she was told the story of a raped woman, who after receiving an apology on behalf of manhood for the reprehensible behavior of the man who raped her, said, “There is no reason to apologize. What happened to me does not define me. Only I define me.” The patient said she would have to work on adapting this view.

There is a growing recognition that traumatic experiences in childhood have the potential to strongly influence outcomes of children and adolescents. There is growing acknowledgment that children exposed to trauma grow up with psychiatric disorders that can be directly traced back to the initial exposure. Unfortunately, symptom checklists followed by matching psychotropic effects of medications to target symptoms often result in a medicalized patient. Although medications may rebalance neuropsychiatric structures and chemistries damaged by trauma, it is essential to provide the patient with practical information, education, and philosophical considerations. A good therapeutic bond between patient and psychiatrist will reassure the patient and result in better outcomes. Accordingly, the construction of a dynamic formulation of the origins of the patient’s symptoms and the ability to explain it to the patient in an understandable, commonsense manner is quite comforting and encouraging. The Dells had it right when they sang, “A little understanding goes a mighty long way.”

Introduction: Mental Health Correlates of Trauma

Understanding and Fostering Resilience in Persons Exposed to Trauma 

Psychiatrists need to understand how living in violent families and neighborhoods increases the likelihood of trauma and the psychiatric sequelae associated with it as well as how to respond in the aftermath.

Trauma Associated With Living in Violent Neighborhoods

-acetylcysteine and bipolar-specific psychotherapies is on the horizon for this bipolar series. But with DSM-5 about to arrive, one more examination of bipolar diagnosis is warranted. After all, if a diagnosis is inaccurate, treatment efforts, however well-intentioned, may misfire.

The formal changes in DSM-5 will not be official or public until this month. But the bipolar disorder workgroup proposed 4 changes on the 

 (since removed in anticipation of publication).

 Two of the proposed changes will tighten bipolar diagnostic requirements, and two will loosen them.

The tightening criteria are (1) diagnosis of hypomania or mania will now require a finding of increased energy along with the rest of the unchanged criteria and (2) bipolar not otherwise specified (BP NOS) becomes bipolar not elsewhere classified (BP NEC), with tighter definitions of subthreshold bipolar variations. The loosening criteria are (1) mixed states will encompass a spectrum of admixtures of manic and depressive symptoms, down to specific minimums and (2) antidepressant-induced hypomania or mania will now qualify a patient for a diagnosis of bipolar disorder.

Will the tighter criteria help address the reported overdiagnosis problem?

 Take the fictional case of 31-year-old Ms Alvarez, who, since age 18, has had many clearly recognizable episodes of depression that last a week or more. When asked, she endorses phases of increased activity and remarkable productivity; increased social interaction; and a confident, positive outlook that is otherwise unusual for her-all on about 4 to 5 hours of sleep. She does not endorse increased energy during these phases, however.

Does she have bipolar II? According to DSM-IV, she might qualify (barring other diagnoses that trump bipolar disorder, such as a mood disorder due to a general medical condition). But because she does not endorse increased energy phases, she does not quite reach a diagnosis of bipolar II according to DSM-5. Will this tighter requirement increase diagnostic accuracy?

Intuitively, the answer seems obvious: surely the harder it is for a patient to meet all the diagnostic requirements, the harder it should be to award a diagnosis of bipolar disorder. Yet surprisingly, if we look at the statistical determinants of diagnostic accuracy, tighter criteria will have little impact. The reward for working through the following review of these statistical determinants is the understanding that the greatest impact of diagnostic accuracy comes from clinicians, not from tightening criteria.

Diagnostic accuracy: positive predictive value

When a clinician tells a patient “you have bipolar disorder,” how likely is it that the diagnosis is correct? In a widely cited study of overdiagnosis, Zimmerman and colleagues

 found that the answer is “less than 50% of the time.” My essay “

Overdiagnosis: Examine the Assumptions, Anticipate New Bipolar Criteria

 questions the broad assumptions that underlie that conclusion. Zimmerman and colleagues derived the 50% diagnostic accuracy figure by calculating a positive predictive value (PPV): in patients said to have bipolar disorder by local clinicians, how many will be found positive by the gold standard (in this case, a structured clinical interview)? In their study, a structured interview did not support the diagnosis in 56% of patients who had been told they had bipolar disorder.

Two key factors determine PPV, and thus determine why in this study the PPV was so low (only 46%). First is the specificity of the test in question, which in this case is the DSM criteria set as applied by the local clinicians. The other determinant of PPV is prevalence-how likely is the illness before the clinician starts trying to diagnose it?

Another related concept needs to be introduced to show that clinicians have more impact on accuracy than the DSM criteria, namely: prevalence is but one form of prior probability. Clinicians can increase prior probability, ie, the likelihood that the patient has bipolar disorder, by assessing other markers of bipolar disorder that are not in DSM.

Compare tightening diagnostic criteria (eg, adding an increased-energy criterion to the required symptoms of hypomania to increase specificity) with increasing prior probability (eg, by asking the patient for additional information not in the DSM criteria: family history, age of onset, course of illness, and response to treatment). As a starting point for this comparison, 

 (first row) presents the results from the Zimmerman study, with the very low PPV of 46%.

In the second row, using the same starting point, prevalence is held constant while specificity is increased. This reflects the intent of tightening changes in DSM-5 to make it harder to confirm the diagnosis. Although the increase in specificity is small, from 86% to 90%, this is likely in the range of what tightening criteria could produce. Note that with this change in specificity, PPV increases from 46% to 55%. (Greater increases in specificity are clinically very difficult to achieve, but even if specificity were somehow to be increased to 95%, the conclusions presented here still hold.


Increasing positive predictive value (PPV) increases diagnostic accuracy of bipolar disorder

In the third row, specificity is held constant at the same 86% value found in the Zimmerman study, while prior probability is increased to 30%. This is what happens when a clinician has a hunch (eg, by inquiring about family history and response to prior treatment attempts) that the likelihood of bipolar disorder underlying Ms Alvarez’s depression is higher than population prevalence (eg, about 1 chance in 3). Note that now PPV increases to 68%: a better than two-thirds chance of accuracy, up from less than 50% as found by Zimmerman and colleagues, and well above the increase associated with a moderate improvement in specificity shown in the second row.


Markers of bipolar disorder not found in DSM-5

Finally, the fourth row shows what happens when a clinician narrows the possibility that the patient has bipolar disorder to a 50/50 chance, before applying DSM criteria. For example, imagine that Ms Alvarez, presenting with depression, had multiple features of bipolar disorder: a first-degree relative with a firm diagnosis; onset of her first depression at age 18; postpartum depression; multiple, brief episodes; a strong adverse reaction to an antidepressant; and no sustained benefit in 4 well-conducted antidepressant trials. With all this, the likelihood that her depression is a bipolar depression is at least 50% (a conservative estimate

). With a 50/50 prior probability, use of DSM criteria with a specificity of 86% achieves a PPV of 83%. This is much higher than can be achieved by tightening DSM criteria to a specificity of 90%, or even 95%.

The analysis above suggests that the tightening of DSM criteria will have only a small effect on diagnostic accuracy. A far greater effect can be achieved if clinicians adopt a practice of routinely assessing the non-DSM markers of bipolar disorder shown in 

 Their presence does not make the diagnosis. Rather, their presence increases the probability that a depression is a bipolar depression.



This is not a novel approach. Routine assessment of these bipolar markers has been part of the assessment of patients at the Harvard-associated mood disorder clinic for 10 years, as part of a 

 suggested that routine assessment of these bipolar markers is “what good clinicians already do.”

Unfortunately, more than half of all mental health care in the US is delivered in primary care settings, where assessment of non-DSM bipolar markers is not “what good clinicians already do.” How can psychiatrists and psychologists improve diagnostic accuracy there? At minimum, they should help primary care colleagues screen as effectively as possible for bipolar disorder.

Screening questionnaires are far from ideal. Their results are too often interpreted as a diagnosis. But they can be used to identify patients who should not receive an antidepressant before further assessment by a mental health specialist. Because the 

 (BSDS) has been found to be more sensitive for bipolar II, it is preferable for use in primary care, where bipolar II is more likely to be missed than bipolar I.

 that assesses all of the factors shown in 

 This version of the BSDS does not require further validation, because the additional questions merely gather data for interpretation by a clinician.

Good clinicians will not only routinely assess non-DSM bipolar markers, they will also encourage their primary care colleagues to do the same, using a screening tool developed for this purpose. These steps will do more for improving diagnostic accuracy across the entire mental health care delivery system than using the new DSM criteria.

 American Psychiatric Association. DSM-5 Development. 

Mitchell PB. Bipolar disorder: the shift to overdiagnosis. 

Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? 

Phelps J, Ghaemi SN. The mistaken claim of bipolar ‘overdiagnosis’: solving the false positives problem for DSM-5/ICD-11. 

 Mitchell PB, Frankland A, Hadzi-Pavlovic D, et al. Comparison of depressive episodes in bipolar disorder and in major depressive disorder within bipolar disorder pedigrees. 

 Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. 

 Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: a probabilistic approach. 

http://www.psycheducation.org/depression/STEPBipolarityIndex.htm

 Ketter TA, Citrome L. Addressing challenges in bipolar diagnosis: what do good clinicians already do? 

 Zaratiegui RM, VÃ¡zquez GH, Lorenzo LS, et al. Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders. 

http://www.psycheducation.org/PCP/launch/downloadMoodCheck.htm

With DSM-5, one more examination of bipolar diagnosis is warranted. After all, if a diagnosis is inaccurate, treatment efforts, however well-intentioned, may misfire.

DSM-5 Won’t Solve the Overdiagnosis Problem-But Clinicians Can

Come next year, psychiatrists will start seeing patients who have purchased new individual and small-group health plans on the state exchanges mandated by the Affordable Care Act. But mental health benefits will differ from state to state, and it is hard to know whether they will meet the requirements of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). Moreover, important issues such as network adequacy as far as psychiatrist coverage is concerned and physician payment rates are also up in the air.

Julie Clements, JD, MPP, Deputy Director of Regulatory Affairs at the American Psychiatric Association, recently conducted a webinar for psychiatrists. She told 

, “A lot of them don’t yet realize how big an issue this is. They are just beginning to understand that the state exchanges will offer private plans and subsidies for individuals of up to 400% of the poverty rate. So this could mean 60 million to 70 million people impacted.”

The Department of Health and Human Services (HHS) issued a final rule on February 25, 2013, that outlines the essential health benefits (EHBs) that all qualified health plans (QHPs) on each state exchange must cover. Those EHBs fall into 10 categories. Two are of prime importance to psychiatric patients: mental health and substance use disorder services, including behavioral health treatment, and prescription drugs.

Almost all 50 states and the District of Columbia have chosen “benchmark plans,” which set minimum levels of benefits for QHPs in each of the 10 EHB categories. The EHB rule is very general with regard to the mental health category and does not address how the MHPAEA affects those minimums.

Clements explains that most states have chosen the largest small-group plan in their state as their benchmark. These typically have less generous mental health benefits than private employer plans. California, for example, has chosen the Kaiser Small Group HMO 30 plan as its benchmark. “Many stakeholders in California have grave concerns over Kaiser’s minimal mental health services,” reports Jane Adcock, Executive Officer, California Mental Health Planning Council. “Recently, Kaiser was found to be out of compliance with access and availability rules and is in a corrective action plan mode.”

States do have the option of supplementing mental health or any other category of benefits within the benchmark plans. But they will not get federal financial assistance to do so, which decreases the likelihood that supplementation will occur, according to Clements. “NASMHPD is learning that states’ approaches to supplementing benefits or substitution are diverse,” explains, Joel E. Miller, Senior Director of Policy and Healthcare Reform, National Association of State Mental Health Program Directors (NASMHPD). “NASMHPD is concerned that this flexibility could affect mental health consumers’ ability to make apples-to-apples comparisons among plans and allow plans to use benefit design to cherry-pick healthier enrollees.”

Minimum mental health coverage in the mental health category theoretically should be affected once the HHS publishes a long-delayed final rule on the MHPAEA. That law-also known as the Wellstone-Domenici Mental Health Parity Act-says that all insurance plans must equalize access for patients with mental health issues with access for medical/surgical patients, and provide equal payment for all physicians billing the same codes (eg, evaluation and management codes).

In a letter to the HHS on March 13, 2013, the American Psychiatric Association voiced concern that states would judge network adequacy for psychiatrists included in QHP networks on the basis of the number of psychiatrists in a network, as opposed to the number of days it takes for a patient to get an appointment with a psychiatrist.

Patient access to medications is also an issue. The HHS declined to order formularies in QHPs to adhere to the Medicare Part D requirement that all drugs in 6 “protected” categories be available. Those 6 include antidepressants and antipsychotics. QHPs will have to offer at least 

• One drug in every United States Pharmacopeia category and class

• The same number of prescription drugs in each category and class as the state EHB benchmark plan

Patients who want an off-formulary drug will be able to file an appeal for it.

“It’s nice to say that people who need a drug that’s not on the formulary can appeal for it, but typically appeals are a lengthy and burdensome process, and this will be a difficult process for many mentally ill patients who seek a medically necessary but not covered drug,” responds Clements. “The drug benefit is still very limiting. Most very sick mental health patients need drugs from at least 3 different classes within the drug formulary.”

Come next year, psychiatrists will start seeing patients who have purchased new individual and small-group health plans on the state exchanges mandated by the Affordable Care Act.

Update on Mental Health Benefits and Substance Use Disorder Services Under the Affordable Care Act

How often are you confronted with an ethical dilemma in your clinical practice? How comfortable-and how prepared-are you to deal with these issues? Have the ethical dilemmas you face become more difficult in recent years?

Those are just a few of the questions posed in the Psychiatric Times Ethics Survey-a survey that turned out to be the largest ever of its kind: 708 psychiatrists took time to respond along with other health professionals, including nurses, psychologists, and students-for a grand total of 1400 responses. Another ethics survey is planned for later this year.

The charts you see here are randomly culled from that ethics survey. The survey included 19 questions that touched on end-of-life issues, boundary issues, confidentiality, and third-party influence.



How often are you confronted with an ethical dilemma in your clinical practice? How comfortable-and how prepared-are you to deal with these issues? Those are just a few of the questions posed in the Psychiatric Times Ethics Survey-a survey that turned out to be the largest ever of its kind.

The Moral Struggles of Practicing Psychiatrists

Some recent studies provide new information about nonpharmacological treatments for ADHD, course of ADHD in preschoolers, solar intensity and ADHD, and age and stimulant use.

Parents of children with ADHD frequently ask whether there are nonmedication treatments that are effective for managing their children’s symptoms of ADHD. A recent meta-analysis provides an answer to this clinically important question.

 This meta-analysis sought to evaluate the effects of dietary and psychological treatments for symptoms of ADHD in children and adolescents. The studies were randomized controlled trials published in peer-reviewed journals that included youths aged 3 to 18 years who had a diagnosis of ADHD or who met symptom criteria based on ADHD rating scales.

Three dietary interventions were included in these analyses: restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation. The restricted elimination diet studies included antigenic foods, general elimination diets, oligoantigenic diets, and elimination of specific provoking foods. The artificial food color exclusion had trials that excluded certified food colors, tartrazine, and unspecified food colors or that implemented a Feingold-type diet. The free fatty acid supplementation included trials of omega-3 supplements and/or omega-6 supplements.

The psychological treatments included cognitive training, neurofeedback, and behavioral interventions. The cognitive training included studies of either attention training or working memory training. The neurofeedback included studies of theta-beta training, training of slow cortical potential, and individualized frequency band training. The behavioral interventions included parent training; combination of child and parent training; combination of parent, child, and teacher training; and child training only.

The outcome measure was pretreatment to posttreatment change in total ADHD symptom severity. The investigators conducted 2 analyses: outcome measure assessment by a rater closest to the therapeutic assessment setting (most likely a parent) and outcome measure assessment by a blinded rater. When assessments were done by an individual such as a parent, both dietary and psychological interventions showed statistically significant effects. However, when assessments where done in blinded conditions, only free fatty acid supplementation and artificial food color exclusion showed statistically significant effects. Neurofeedback, cognitive training, and restrictive elimination diets did not elicit a significant decrease in children’s symptoms of ADHD under blinded conditions.

What are the implications of these findings for treatment of ADHD in youths? In studies of medication treatment for children and adolescents with ADHD, standardized mean differences in pretreatment and posttreatment are approximately 0.9. Mean difference found for free fatty acid supplementation was 0.16 and artificial food color exclusion was 0.42: both are substantially below that found for medication treatment. The authors conclude that it is important to identify more effective nonpharmacological treatments for children and adolescents who have ADHD.

Polyunsaturated fatty acids added to stimulants

Another question posed by parents is whether adding fatty acids to stimulant treatment will further diminish ADHD symptoms. The addition of polyunsaturated fatty acids to stimulant treatment for children aged 6 to 12 years with ADHD was investigated.

 In this double-blind, placebo-controlled, 10-week trial, 40 children were randomized to either methylphenidate or methylphenidate plus polyunsaturated fatty acids (430-mg capsules containing 241 mg of docosahexaenoic acid, 33 mg of eicosapentaenoic acid [EPA], and 180 mg of omega-6). The outcome measure was a 25% decrease in ADHD symptoms on the Parent ADHD Rating Scale.

No significant differences were found in rates of inattention, hyperactivity, and impulsivity between the two groups. These investigators conclude that the addition of polyunsaturated fatty acids to stimulants affords no clinical benefit. However, the dose of EPA was low, which may have partially accounted for lack of improvement.

When ADHD is diagnosed in a preschooler, it is important to know whether the symptoms will persist in elementary school. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) follow-up provides information about the course of preschool ADHD.

 The PATS randomized trial to assess the efficacy of methylphenidate included 207 preschoolers aged 3 to 5 years with ADHD. The children were followed for 6 years and received assessments at years 3, 4, and 6.

The most striking finding from this study was that nearly 90% of the children with moderate to severe ADHD continued to have ADHD at the 6-year follow-up, with generally no changes in ADHD symptom severity. Those children who had comorbid oppositional defiant disorder or conduct disorder had more severe ADHD symptoms and were more likely to have persistence of an ADHD diagnosis. The most commonly prescribed medications during the follow-up period were stimulants. Other, less frequently used medications were atomoxetine and clonidine or guanfancine. From year 3 to year 6, there was an increase in the prescription of both SSRIs and antipsychotics.

The researchers point out that the majority of these preschool children had received a controlled trial of methylphenidate and that their parents had received training for managing ADHD; yet, the children continued to have a diagnosis of ADHD in mid-childhood. The researchers concluded that more comprehensive or intensive treatments are warranted in preschoolers in whom ADHD is diagnosed.

Children with ADHD often have sleep-onset insomnia and a delayed circadian phase. Since bright light may affect circadian rhythm, Arns and colleagues

 investigated the relationship between environmental light exposure and the prevalence of ADHD. Solar intensity (kilowatt hours/square meter/day) data and ADHD prevalence estimates were obtained from most of the US and 9 non-US countries. A relationship was found between the prevalence of ADHD and solar intensity, which explained 34% to 57% of the variance in ADHD prevalence.

Higher solar intensity was associated with lower prevalence of ADHD. This relationship was not found for diagnoses of autism spectrum disorder or MDD. The findings suggest that high solar intensity may be a protective factor for ADHD. The authors recommend that if prospective studies replicate these findings, then interventions regarding light exposure could be developed for children with ADHD. For example, exposure to intense sunlight during the day and reduced light exposure at night may reduce some ADHD symptoms.

In a population-based nationwide study in Iceland (which has stimulant utilization rates for ADHD similar to those of the US), Zoga and colleagues

 examined the relationship between age at school entry and academic performance and use of stimulants for ADHD. The study population included 11,872 children who took a standardized test in both fourth grade (age 9) and seventh grade (age 12). Primary outcome measures were standardized test scores in mathematics and language arts. Prescription of stimulants for ADHD was a secondary outcome measure.

In mathematics and language arts, mean test scores were the lowest among the youngest children in the class. At age 9, the youngest third of children in the class had an 80% to 90% increased risk of scoring in the lowest decile compared with the oldest third. This risk diminished modestly to 60% at age 12. Between the ages of 7 and 14 years, children in the youngest third of the class were 50% more likely to have stimulants prescribed for them than were those in the oldest third of the class. Overall, girls were less likely to be treated with stimulants than were boys with ADHD. The researchers concluded that relative age among classmates affects both academic performance and stimulant use. They recommend that relative age be considered when evaluating children for a diagnosis of ADHD.

The results of this study raise important considerations regarding developmental differences among children based on age when entering school. These findings are particularly important in light of the fact that academic and behavioral expectations are the same irrespective of a child’s relative age.

Dr Wagner is the Marie B. Gale Centennial Professor and Vice Chair in the department of psychiatry and behavioral sciences and Director of Child and Adolescent Psychiatry at the University of Texas Medical Branch at Galveston.

Sonuga-Barke EJ, Brandeis D, Cortese S, et al; European ADHD Guidelines Group. Nonpharmacological interventions for ADHD: systematic review and meta-analyses of randomized controlled trials of dietary and psychological treatments. 

Assareh M, Davari Ashtiani R, Khademi M, et al. Efficacy of polyunsaturated fatty acids (PUFA) in the treatment of attention deficit hyperactivity disorder: a randomized, double-blind, placebo-controlled clinical trial.

 Riddle MA, Yershova K, Lazzaretto D, et al. The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-year follow-up. 

Arns M, van der Heijden KB, Arnold LE, Kenemans JL. Geographic variation in the prevalence of attention-deficit/hyperactivity disorder: the sunny perspective. 

ZoÃ«ga H, ValdimarsdÃ³ttir UA, HernÃ¡ndez-DÃ­az S. Age, academic performance, and stimulant prescribing for ADHD: a nationwide cohort study.

An Update on ADHD

CME credit for this article is now expired. It appears here for your reference.

The electroencephalogram (EEG) has a limited but definitive role in understanding and managing psychiatric conditions. When the presentation is unusual, a neurological workup that includes an EEG is essential. In conditions in which EEG abnormalities are demonstrably common, an EEG should be considered part of the essential workup. A simplified EEG can have substantial diagnostic usefulness, particularly in emergency department settings. The abbreviated EEG can be done in a matter of minutes using a 10- or 12-channel recording instrument.

The electroencephalogram (EEG) has a limited but definitive role in understanding and managing psychiatric conditions. When the presentation is unusual, a neurological workup that includes an EEG is essential.

Psychiatric Times Vol 30 No 5