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<span class="svspan">StrongVeterans.com Blog</span>Inadequate Trials of Prazosin: Potential Missed Opportunities for Veterans With PTSD

The 2010 VA/DoD Clinical Practice Guideline recommends that clinicians consider the use of prazosin, an alpha 1 adrenergic receptor antagonist used to treat hypertension, for PTSD-related nightmares. Sleep problems are common in PTSD and may be a core feature. Research has suggested that, although prazosin has been steadily disseminated in the VA, it still may be underutilized and underdosed. In our recent study, we examined a cohort of veterans with PTSD initiating prazosin to characterize their dosing patterns and duration of use.

Administrative data identified veterans with PTSD according to ICD-9 codes. Prazosin use following initiation utilized refill data, and prazosin doses were calculated based upon total milligrams and day’s supply dispensed.

A total of 12,844 veterans with PTSD were new prazosin users during 2010. On average, the patients were 53 years of age, 92% male, and taking 6 medications at the time of prazosin initiation.

Prazosin doses generally increased during treatment, reaching an average maximum dose of 3.6 mg/d. However, only 14% reached the minimum guideline-recommended dose of 6 mg/d for an adequate trial.

Regarding duration of use, 20% of the patients never refilled their initial prazosin prescription, and 18% discontinued within 6 months. The remaining 61% took prazosin for more than 6 months, with 38% of the total sample persisting for at least 1 year. Patients with concurrent SSRI/SNRI antidepressants were more likely to maintain prazosin treatment for a year compared to non-antidepressant users. Additionally, one-year users were older and had more concurrent medications.

Recent work by Murray A. Raskind, MD, and colleagues has noted that pretreatment physiological parameters such as blood pressure in patients with PTSD may serve as a clinically useful biomarker for helping to predict the response to prazosin. Patients who had higher baseline blood pressure and smaller baseline blood pressure drop (standing for 2 minutes for supine) showed substantially greater PTSD symptom improvement associated with prazosin treatment. Although preliminary, these findings suggest that increased peripheral noradrenergic tone is a potential biomarker for a clinically therapeutic response to prazosin in PTSD, and they may also account for varied findings using prazosin for nightmares.

Although large pharmacy databases are very useful for addressing some questions, they cannot answer others. In the present case, we don’t know why the drug was discontinued after one year in two-thirds of the patients. Was it because patients and/or providers found it ineffective at lower doses? Was it because of side effects? Was it because prescribers did not titrate the dose to optimal levels to achieve full symptom response?

Our findings justify further investigation to identify factors related to the common failure to reach recommended prazosin dosage guidelines for PTSD-related nightmares. The answer to this question and others would provide clinicians who treat patients with PTSD a vital opportunity for more optimal use of this low-cost, guideline-recommended treatment.

REFERENCE

Raskind MA, Peskind ER, Millard S, et al. Baseline blood pressure is associated with PTSD symptom response to prazosin in active duty combat soldiers. Poster presented at: 53rd Annual American College of Neuropsychopharmacology Meeting; December 9, 2014; Phoenix, AZ.

Financial disclosure: Drs Bernardy and Friedman had no relevant personal financial relationships to report.

Pellagra: Niacin Deficiency and Mental Illness

In our previous post, we stated that a single nutrient is unlikely to have a profound effect on a serious mental health condition, but the fascinating story of niacin and pellagra is an exception to that rule.

Pellagra (meaning rough skin) was first described in 1735 by a Spanish physician, Don Gaspar Casal, and was called “mal de la rosa” due to the characteristic red rash on the hands and feet. Early researchers linked pellagra with poverty and a corn-based diet, suggesting that spoiled maize was at fault. Almost 2 centuries later, a pellagra epidemic occurred in the southern United States. Despite the link to the poor person’s diet , the wisdom at that time was that pellagra was contagious and perhaps hereditary, and pellagrins, as they were called, were shunned.

The relevance of pellagra to psychiatry is that symptoms can include confusion, psychosis, and depression. Pellagra typically affects the skin, the gut, and the brain, with a characteristic manifestation referred to as the 3 Ds—dermatitis, diarrhea, and dementia—and it may lead to death.

In 1914, Joseph Goldberger, a physician and clinical epidemiologist, was invited by the US Surgeon General to investigate pellagra. Careful reviews of the literature indicated to him that pellagra was a dietary disease , not an infectious one. Cases were being reported in mental hospitals and orphanages in which the residents, eating a mainly corn-based diet, would get the disease, whereas the staff, despite daily contact with the patients, would not. Outbreaks also appeared in cotton mill villages where the diet was mostly cornmeal, molasses, salted pork, and lard.

Goldberger began running trials in orphanages and asylums by manipulating their diets, and those given fresh meat, milk, and legumes were no longer sick. He also conducted experiments in which he showed he could induce pellagra in healthy men (prisoners who were offered pardons for participating) by feeding them a corn-based diet. Thus, Goldberger established that pellagra was a disease of a faulty diet, not infection.

Despite his repeated controlled experiments using diet manipulation, people continued to hold to the prevailing wisdom that pellagra was infectious. And so, in 1916, he and volunteers (his wife being one of them) were exposed to the blood, urine, feces, and epidermal scales of people with pellagra, and not a single person developed it. Goldberger, however, was unable to isolate the ingredient that was causing the condition. In 1937, another scientist, Conrad Elvehjem, determined that niacin was the essential dietary factor. Fortification of food with niacin began in 1941.

Although underreporting of pellagra was typical, records suggest that at least 3 million cases had occurred, with over 100,000 deaths, in America in the 40 years until its true cause was determined. One state hospital, in Goldsboro, NC, estimated that nearly 1 in 5 admissions between 1930 and 1932 were solely because of pellagra psychosis, an easily preventable/treatable nutrient deficiency.

The Diagnostic and Statistical Manual of Mental Disorders acknowledges that nutritional conditions such as niacin deficiency can cause neurocognitive disorders. But, we wonder, while niacin therapy has been accepted for the eradication of pellagra, is it not possible that a combination of nutrients may have had far superior effects? And, if Walter Mertz was correct when he declared in 1994 that the era of single-nutrient cures for disease was over, what other mental symptoms might be eradicated with combinations of nutrients as treatment? We will cover these topics in future blog entries.

This blog entry is adapted from a previous entry that can be found at http://www.madinamerica.com/2013/05/jeopardizing-your-wife-to-prove-a-theory-pellagra-as-an-example-of-a-nutrient-deficiency-disease/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

<span class="svspan">StrongVeterans.com Blog</span>PTSD in US Veterans

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can develop after a traumatic or extremely stressful event, such as military combat, a physical or sexual assault, or a serious accident. PTSD symptoms include problems such as re-experiencing the trauma in the form of intrusive memories or nightmares, not wanting to think or talk about what happened, having persistent negative thoughts and feelings, and feeling “on guard” or vigilant for threat.

The history of the PTSD diagnosis in the United States is intertwined with US military history; in fact, PTSD was added to the Diagnostic and Statistical Manual of Mental Disorders in 1980 largely due to research on psychological problems facing Vietnam veterans. Although much research has been conducted on PTSD among convenience samples of active duty members and veterans, few contemporary studies have examined the prevalence and correlates of PTSD in nationally representative samples of US veterans, which is necessary to draw conclusions about the entire population of veterans in our country. Consequently, surprisingly little is known about how prevalent PTSD is in the current population of US veterans, how often US veterans are exposed to different types of traumas, how frequently other types of psychiatric disorders co-occur with PTSD, and what types of sociodemographic, military, and psychosocial factors are associated with PTSD in this population.

In the National Health and Resilience in Veterans Study, we examined the prevalence of trauma exposure, PTSD, and other psychiatric problems in a contemporary, nationally representative sample of 3,157 US veterans. We found that 8.0% of veterans screened positive for PTSD in their lifetimes, a rate slightly higher than those observed in the general US adult population by Pietrzak et al and Kessler et al (6.4% to 6.8%). Lifetime probable PTSD rates were higher among female veterans (19.4 % vs. 6.8% in men) and among younger veterans (23.8% in those aged 21–29 years versus 3.5% in those aged 60 years or older).

Although clinicians working with veterans often assume that veterans’ PTSD symptoms result from military combat, the veterans in our study frequently reported that their PTSD symptoms resulted from other types of trauma, such as physical or sexual assault during childhood. In fact, the trauma type that veterans most frequently endorsed as their “worst” traumatic experience was the sudden death of a loved one (27.5%), a finding consistent with other research in the general US population. Relative to veterans without PTSD, veterans with PTSD were 2.3 to 19.1 times more likely to screen positive for psychiatric problems, such as depression, anxiety, or alcohol and drug problems, and 9.7 to 11.8 times more likely to endorse suicidal thoughts and behaviors. However, veterans who endorsed protective psychological and social factors, such as greater resilience, community integration, and supportive relationships, were less likely to report PTSD symptoms.

This study indicates that PTSD is a prevalent disorder among both combat and noncombat veterans in the United States, particularly among female and younger veterans, and is associated with high rates of co-occurring psychiatric problems. Interventions designed to increase protective psychosocial factors may help mitigate PTSD risk among US veterans, although further research is needed to examine this possibility.

Financial disclosure: Drs Wisco and Marx had no relevant personal financial relationships to report. Dr Pietrzak is a consultant for Cogstate and has received grant/research support from NIH and DoD. ​

Costs of Depression in the Workplace

Over the past two decades, together with my colleagues, I have undertaken many assessments of the costs of depression. One robust finding from this body of research, which is echoed in my latest study, is the enormity of the workplace burden of illness. A variety of reasons explain why this particular cost component is so large, with more than half of the costs of depression attributable to workplace productivity losses.

Depression is a highly prevalent, chronic illness that affects people especially in their prime working-age years. Furthermore, many of its symptoms can be highly impairing, particularly from a workplace perspective, whether the needed skills require strength, dexterity, concentration, or interpersonal capability. These symptoms include the following:

  • cognitive impairments, due to reduced ability to focus
  • behavioral impairments, due to social withdrawal or lack of motivation to accomplish even routine tasks
  • physical impairments, due to bodily pain or fatigue
  • emotional impairments, due to increased moodiness or irritability

In many cases, the symptoms of illness are not so severe that sufferers withdraw entirely from the labor force, resulting in a very sizable pool of depressed workers at any given time. Because of this particularly problematic constellation of disease-specific factors, no employer is exempt from the adverse consequences of depression in the workplace.

Employability for individuals with depression changes at different points in the business cycle. When the economy is growing, people with depression tend to remain employable. But, in periods of economic decline, employees with depression bear a disproportionate burden compared with their nondepressed counterparts, especially among those aged 50 years and older. This is both because employees with depression are generally more likely to lose their jobs during economic downturns and because the buffer of part-time work is not as widely available to those with depression. Of course, distinguishing cause and effect in this context is difficult since the presence of depression is likely to diminish labor market attachment, even as unemployment itself could contribute to a more fragile state of emotional well-being.

All of these workplace findings highlight a tension that exists between societal interests and those of individual employers in the context of optimal patient management. On the one hand, society is better served when depressed workers are drawn into employment situations, as the opportunity cost of their lost productive capacity is at least partially recaptured through their newfound labor market activity. In addition, for some depression sufferers, health care coverage is available only via employers. On the other hand, individual employers tend to incur added costs as the employment rate of depressed people rises.

Thus, the complex interplay of work status, depression symptoms, and depression treatment warrants continued study. Shining a bright light on the relative impact of these different contributors to direct cost changes and understanding how they have moved historically would offer insight into the available levers that could be brought to bear in most effectively managing resource utilization in this context over time.

Financial disclosure: Dr Greenberg had no relevant personal financial relationships to report.

See the FOCUS COLLECTION of J Clin Psychiatry articles on healthcare economics.

Assessing Patients’ Capacity to Refuse Medical Care

Few people dispute the assertion that in a free society we all have the right to make our own mistakes—including our right as patients to refuse care we do not want. Indeed, this concept of informed refusal is well established in both the medical and behavioral health literature as well as in the law.

The answer to the question of how much understanding a patient must exhibit to be considered "informed" is less clear, however. For behavioral health patients who have concomitant, serious medical illness, the answer is often especially murky.

As Jeffrey P. Spike, PhD, and I recently discussed in an article in The Primary Care Companion, our experience is that psychiatrists and adult medicine physicians often assess patient capacity regarding the refusal of care in very different ways.

The 3 cases we presented in our article highlighted the tendency of psychiatrists to give patients the freedom to refuse care even if they do not express a full understanding of the details of their illness—provided that they do exhibit a basic understanding and have plans for meeting basic needs.

Adult medicine physicians, on the other hand, are inclined to require patients to state a more complete understanding of their illness and the consequences of refusing care, especially when that refusal might result in a serious, adverse medical outcome.

We believe this difference in assessing capacity is a reflection of psychiatric and adult medicine physicians' different experiences of the health care world. Because psychiatrists frequently interact with the legal system in competency hearings, because most behavioral illness is chronic and fluctuates over time, and because the physiologic consequences of psychiatric illness are rarely irreversible (beyond acute suicidal or homicidal behavior), psychiatrists are generally reluctant to remove decision-making power from patients. While the process of psychiatric consultation often facilitates patients’ ability to understand their illness in a general way—especially regarding social consequences—asking psychiatrists to specifically evaluate medical illness decision-making capacity is often frustrating, as their frame of reference is the mental health system and the courts.

In contrast, because adult medicine physicians face acute medical problems that do not fluctuate but frequently deteriorate without treatment, they are generally reluctant to allow patients to suffer the ill effects of what they perceive to be harmful, irreversible medical decisions. While adult medicine physicians are taught to beware of paternalism, asking them to respect psychiatric patients’ self-determination is often frustrating, as their frame of reference is the intensive care unit and the morgue.

When a strong difference of professional opinion occurs among the clinicians caring for a psychiatric patient with serious medical illness, we recommend two interventions. First, we encourage engaging both the patient's primary medical care clinician and primary behavioral clinician for input; hopefully, they have relationships and history with the patient and can provide context to help resolve these situations. Second, we strongly encourage obtaining formal ethics consultation, integrating both the psychiatric and hospital medicine approaches to assessing capacity—which we outline in our article—in order to find an empathic and pragmatic solution to these cases of refusal of care.

Financial disclosure: Dr Tunzi had no relevant personal financial relationships to report.

The Search for a Single-Nutrient Solution to Mental Illnesses Is Outdated

Our previous blog entry showed that the knowledge that good nutrition is essential for mental health is very old. Here, we would like to talk about the misguided approach taken by many scientists over the last century of looking for a single nutrient that will have profound effects on brain function.

Two reviews we have conducted of the scientific literature on the use of vitamins and minerals for the treatment of mood disorders and ADHD found dozens of reports from about 1910 to the present. Many nutrients have been studied, including the B vitamins; vitamins C, D, and E; and calcium, chromium, iron, magnesium, zinc, selenium, choline. But scientists were not studying nutrition in the way in which humans have evolved to require nutrients, ie, consumed together and in balance. Studies generally followed a “drug trial model” by giving patients a single nutrient and seeing if their symptoms improved.

Experimental science has made great progress by adhering to the principle that only one variable can be altered at a time and all other variables must be controlled. This approach aided the post–World War II golden era of drug development. A few decades ago, though, psychologists demonstrated the value of complex independent variables, investigating multivariable, usually manualized, treatments such as cognitive-behavioral therapy. The two of us thought this debate was over and that, especially in the realm of nutrition, multivariable treatments were accepted. But one of Julia’s manuscripts on multinutrient treatment was rejected recently by a leading American psychiatry journal with one reviewer complaining, “We can’t tell which is the active ingredient.”

Has the single-nutrient, “magic bullet” approach to mental illness yielded benefits? Yes, but the benefits are consistently modest. Calcium supplementation modestly improves mood; zinc or copper supplementation modestly improves mood and can improve attention; and various B vitamins administered singly modestly improve mood. Some recent research suggests that omega-3s or vitamin D administered in isolation can improve some psychiatric symptoms to a modest degree.

We acknowledge that for some physical illnesses, single nutrients can mean life or death. Scurvy is a great example of this because vitamin C can prevent and cure it. Pellagra and its psychosis can be cured with niacin therapy (more on that in our next blog entry). Also, vitamin B12 can completely eradicate pernicious anemia, an illness that often presents with psychiatric symptoms. And, what woman in the Western world who is planning a pregnancy is unaware of the need to take folic acid to prevent birth defects, although other B vitamins have also been shown to be beneficial?

What is troubling about the single-nutrient literature is that hundreds of studies and millions of research dollars have been wrongly based on the idea that a treatment must consist of just one nutrient at a time. The esteemed nutrition researcher Walter Mertz understood the fallacy in this way of thinking. Twenty years ago, he declared that all of the single-nutrient–related diseases had most likely been identified and that all future discoveries of health-related nutrition would consist of complex nutrient formulas. In the last decade or so, studies of broad spectrum or complex nutrient treatments have been conducted. We hope our future blog entries will convince you that broad-based nutrient supplementation is the most logical treatment of illnesses such as dysregulated mood, obsessions, impulsivity, hallucinations, and scattered attention, to name a few.

This blog entry is adapted from a previous entry that can be found at http://www.madinamerica.com/2013/05/the-inane-search-for-magic-bullets-to-treat-mental-illness/.

Financial disclosure: Drs Kaplan and Rucklidge had no relevant personal financial relationships to report, and no company has ever funded any of their studies.

Can We Reduce School Shootings by Better Understanding Boys’ Brains?

As mental health professionals, we need to be acutely aware of a troubling phenomenon: the disenfranchisement of young boys in our homes and schools. This phenomenon has been occurring over the past several decades, often producing confused and violent boys and young men. At their earliest, formative ages, young boys’ behavior is being condemned by society. Some boys are reaching their teenage and young adult years confused about their identity and appropriate social norms.

The result? A steady spate of young males committing gun violence at Marysville Pilchuck High School‬ in Washington, UC Santa Barbara, Seattle Pacific University, Reynolds High School in Oregon, Sandy Hook Elementary in Connecticut, and elsewhere.

How did we get here?

In my recent book Raising Boys by Design, co-authored with brain science expert Michael Gurian, we noted a cultural trend to label boys as morally defective, hyper, undisciplined, or ‘problem children’ when frequently the problem is not the boys but the family, schools, and institutions that do not understand their brain chemistry and specific needs. Condemning their actions during early developmental years sends boys the message that their identity is something to be ashamed of. The resulting behavior can be shocking. Note these worrisome statistics:

  • Boys are diagnosed with learning disabilities at almost triple the rate of girls
  • Boys are almost twice as likely to repeat kindergarten as girls and more than twice as likely to be suspended
  • Boys receive 67% of the D’s and F’s given in school
  • Three times as many boys are considered mentally disabled compared to girls
  • 67% of all children held back in class are boys
  • 73% of children diagnosed with learning disabilities are boys
  • 81% of suicides among those aged 10–19 years are males
  • 80% of diagnosed behavioral disorders are in boys
  • 80% of children taking Ritalin are boys
  • 89% of incarcerated youths aged 15–17 years are boys

With more testosterone and less emotive brains than girls, boys express themselves much more physically than girls, especially at younger ages. It is absolutely natural, healthy, and necessary for young boys to expend their energy and emotions through physical activity.

Yet today, we have created a culture where normal behavior by boys is often instantly labeled as unruly and unacceptable. Throw in social media, technology addictions, and continued shortages of male mentors for young boys, and more problems arise.

So, what can we do?

We need to get brain research material to, and engage in conversations with, all adults who raise, teach, and care for young boys. Understanding the physiology of a boy’s brain and what stimulates it and allows it to be engaged and focused is essential.

Simple changes in environment to allow boys the physical outlet they need to focus can make a huge difference. For teachers, punishing a young boy by removing recess can be counterproductive, as physical activity is a key component in his brain development. Allowing a boy to sit on a large ball in the classroom, subtly bouncing, instead of on a chair, provides stimulation to engage his brain and help him better focus on the teacher. For parents, talking to your son while playing catch or taking a walk will enable him to focus much better than having him sit still at a table for a 15–minute discussion.

It is not easy to teach and raise young boys. I know, as I have 2 young boys myself. It can be difficult to know what is healthy, normal behavior and what crosses the line into aggression or even violence. But we need to figure it out and recognize that what we are doing today is not working. For the future of our young boys and all of us, we need to make understanding boys a priority.

Financial disclosure: Drs Jantz is co-author of the book Raising Boys by Design.

Assertive Community Treatment Teams: Questions for Discussion

Our article "The Assertive Community Treatment Team: An Appropriate Treatment for Medical Disorders That Present With Prominent Psychiatric Symptoms" makes a case for the use of Assertive Community Treatment (ACT) teams for patients with mental disorders due to a general medical condition when the psychiatric manifestations are severe and cannot be managed in a medical clinic. An ACT team is a multidisciplinary group that provides individualized services to each consumer by going into the community (eg, a day program, a diner) or the consumers’ homes. The ACT team provides 24/7 care with the ultimate goal of community integration. The outreach is assertive, and the team persists in the face of failure. Due to a low client-to-staff ratio, the team can provide integrated services, including psychopharmacologic, substance abuse, and rehabilitative treatment and social and family services. ACT teams are often used for psychiatric patients with a history of noncompliance with treatment.

In our article, we described a young woman with Graves disease who had difficulty following treatment recommendations and who was misdiagnosed with bipolar I disorder. She would periodically exhibit irritability, agitation, and threatening behavior requiring hospitalization in a psychiatric unit. Physical signs and symptoms such as cardiac palpitations, tachycardia, hair loss, weight loss, and hyperphagia would usually accompany the psychiatric symptoms. However, there was a tendency to treat her medical and psychiatric symptoms separately and in relative isolation. The consensus of our ACT team was that she had Graves disease masquerading as a bipolar disorder. This diagnosis was based on the temporal association between clinically significant irritability and abnormal thyroid function tests. When hyperthyroid and mood symptoms co-occur, the integration of medical and psychiatric treatments should be a priority. ACT teams are suited to this task.

Here, we consider 3 questions regarding medical-psychiatric issues.

  1. What other medical-psychiatric conditions can be effectively treated by ACT teams?
    Our state hospital ACT team has been treating a patient with serious mental illness (SMI) and water intoxication due to primary polydipsia; the patient has had several medical hospitalizations. Hospitalization for water intoxication is predicated on a worsening of the psychiatric condition and a co-occurring increase in cognitive impairment. The ACT team initiates emergency hospitalization procedures and, after discharge, closely monitors the patient and encourages fluid restriction. We believe water intoxication is an example of a medical-psychiatric interaction that has rarely been studied in SMI outpatients. In fact, we could find only 1 article estimating the incidence of primary polydipsia (15.7%) in an SMI outpatient population. We wonder what medical-psychiatric conditions other ACT teams encounter that are similar in complexity to this.
  2. How might ACT teams routinely be referred patients with medical disorders that present with prominent psychiatric symptoms?
    At first, we thought of contacting medical-psychiatric inpatient units within our region to find out if they would be discharging patients who could benefit from ACT team services. However, we were unable to locate any medical-psychiatric inpatient units in the New York City region. The University of Rochester Medical Center might have the only medical-psychiatric unit (or complexity intervention unit [CIU]) in New York state, according to Telva E. Olivares, MD, Medical Director of the Behavioral Medical Surgical Unit. In operation for approximately 7 years, this 20-bed unit provides acute inpatient medical care for consumers “with mental illness and behavioral complexities, including alcohol withdrawal, delirium, catatonia, personality disorders, Munchausen, somatization, and the usual common medical reasons for admissions.” The Rochester ACT team admits some of their patients to this unit. If the New York City area has no med-psych units, perhaps inpatient consultation-liaison units could play a role in referrals to ACT teams for patients with medical disorders that present with prominent psychiatric symptoms. Would current ACT teams find this workable, or would a new type of ACT team need to be set up? This brings us to our final question.
  3. Are psychiatric ACT teams prepared to treat the medical-psychiatric patient?
    Medical monitoring and collaboration with the primary care treatment team can be added to the integrated services offered by ACT teams. The presence of nurses on a multidisciplinary ACT team has been shown to further improve integration. Unfortunately, many psychiatric ACT teams are not comfortable taking responsibility for treating common nonpsychiatric health concerns like diabetes, hypertension, and obesity. Dr Olivares told us that the Rochester ACT team includes a nurse practitioner and other nursing staff, and nurses have been very helpful in managing some patients with diabetes and hypertension. The role of psychiatric ACT teams can be expanded to include such integrated care but would require a reassessment of staffing and training.

 

Health care integration and cost-effective care remain major challenges.

Financial disclosure: Drs Kanofsky and Woesner had no relevant personal financial relationships to report.

Acknowledgments: We thank Helle Thorning, PhD, MS, LCSW, for her thoughtful and focused feedback. She is a Research Scientist and Director of the ACT Institute, Center for Practice Innovations, Division of Mental Health Services and Policy Research at the New York State Psychiatric Institute. The ACT Institute trains members of the 78 New York State ACT teams.

We also thank Telva E. Olivares, MD, for her personal communications.

<span class="svspan">StrongVeterans.com Blog</span> The Burden of Military Sexual Trauma in US Veterans

Sexual harassment and sexual assaults occurring within the military have begun to receive increased public attention in the wake of recent reports of the high prevalence of sexual traumas among returning veterans from Iraq and Afghanistan, as well as the public testimony of survivors and their advocates. The term military sexual trauma (MST) was developed to aid in screening and advocacy efforts within the Department of Veterans Affairs (VA). The VA defines MST as “sexual harassment that is threatening in character or physical assault of a sexual nature that occurred while the victim was in the military regardless of geographic location of the trauma, gender of the victim or the relationship to the perpetrator.” Previous studies have reported a range of estimates of the prevalence of MST, in part due to differences in the samples studied or the definition of MST used.

In our study of a contemporary, nationally representative sample of US veterans spanning World War II to more recent war eras, we found that a substantial portion of US veterans—7.6%—reported a history of MST, including 32.4% of female veterans and 4.8% of male veterans. Factors positively associated with MST in our study included female sex, younger age (the highest rate of MST was in veterans aged 18–29 years), racial/ethnic minority status, enlisted status, and history of childhood sexual abuse.

Veterans with a history of MST in our study were 2–3 times more likely than those without a history of MST to screen positive for PTSD, depression, generalized anxiety disorder, and social phobia and to report current thoughts of suicide, as well as a history of suicide attempt. They also reported greater severity of somatic symptoms, as well as lower mental and cognitive functioning and quality of life. Notably, a history of MST was associated with increased likelihood of engagement in mental health treatment, independent of PTSD and depression, suggesting that the experience of MST, in and of itself, may motivate mental health treatment seeking in veterans. Taken together, these findings suggest that MST is associated with a broad range of negative health effects and underscore the importance of integrated health care for veterans with a history of MST.

The VA has implemented universal screening initiatives and dedicated clinicians for coordination of care of veterans with a history of MST. However, underreporting of MST is thought to be common, and the majority (69.4%) of veterans with a history of MST in our study reported that the VA is not their primary source of health care. Thus, it may be helpful for health care providers in all sectors of the health care system to screen for MST in veterans and to be aware of the broad range of negative health outcomes associated with MST in this population. Expanding such efforts beyond the VA health care system may further aid in reducing the stigma faced by veterans with a history of MST and may be helpful in further reducing the culture of silence surrounding this issue.

Financial disclosure: Dr Klingensmith had no relevant personal financial relationships to report. Dr Pietrzak is a consultant for Cogstate and has received grant/research support from NIH and DoD.

For related material on mental health issues in the military, please visit StrongVeterans.com.

Behavioral Interventions for Patients With Dementia in Long-Term Care

When treating patients with dementia, behavioral approaches should usually be the first step in reducing behavioral disturbances. Nurses, social workers, activities therapists, and psychologists, for the most part, understand this point better than physicians do. Physicians may be too quick to prescribe medications to manage distressing or disruptive behaviors.

When patients with dementia display such behaviors, we must try to understand what specific needs underlie these behaviors. I think the proper mindset is, What are patients trying to tell us? Are they in pain? Are they scared? Is it too noisy? Is it too hot? Is it too cold? Is the behavior related to an old routine at this time of day? What unmet need is being expressed?

Is a patient upset because his daughter’s in Florida for the winter, and he doesn’t understand why he hasn’t seen her? Is the patient scared or angry, and, if so, about what? Is the patient having trouble hearing or seeing? Is the patient medically ill? A fundamental principle of geriatrics care is to evaluate possible medical or other reasons for behavioral problems. To me, the satisfaction of practicing geriatric medicine is the opportunity to play Sherlock Holmes under circumstances like this and try to figure out what it is that’s wrong and try to address it in a specific way rather than reaching for the prescription pad.

A December 2014 NPR story described a Minnesota nursing home facility that was able to eliminate the off-label use of antipsychotic agents for problematic behaviors by enacting a program of behavioral interventions . Tools include validation, redirecting, pet therapy, aromatherapy, massage, and white noise, as well as playing old music and providing activities that dispel boredom, such as balloon “volleyball.” A 2013 New Yorker article described a facility in Phoenix that also uses this type of individualized approach for patients with dementia so that no off-label antipsychotics are used. The atmosphere is relatively peaceful because people’s needs are addressed, focusing on their comfort in particular. Snacks are wheeled around during the day because patients may forget to eat and then not ask for food when they get hungry. Televisions are usually turned off because many shows can upset patients and distract the staff. Patients’ schedules are not dictated. Patients are allowed to continue habits from their careers, such as walking around as if working in retail or looking in staff members’ mouths as if back in the dentist’s office. Family members and staff are encouraged to accept rather than correct patients’ mistaken ideas. For example, if I’m somebody with dementia asking over and over again where my deceased wife is, and I get upset about it repeatedly, you might say to me, “Well, she may be back later. Let’s have a bowl of ice cream,” and I might very well be content with that.

Medications shouldn’t be the starting point for managing behavioral problems, except in emergencies. Behavioral interventions should be used to identify the source of problems and address them.

Financial disclosure: Dr Tariot is a consultant for Abbott, AbbVie, AC Immune, Boehringer Ingelheim, California Pacific Medical Center, Chase, CME Inc, Corium, GliaCure, Lundbeck, Medavante, Otsuka, and Sanofi-Aventis; both is a consultant for and has received research support from AstraZeneca, Avanir, Bristol-Myers Squibb, Cognoptix, Janssen, Merck, and Roche; has received research support only from Baxter Healthcare, Functional Neuromodulation, GE, Genentech, Novartis, Pfizer, and Targacept; has received other research support from NIA and AZ Department of Health Services; is a stock shareholder of Adamas; and is a contributor to a patent owned by the University of Rochester, “Biomarkers of Alzheimer’s Disease.”

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