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<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; 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.”

The Use of Medications in Patients With Dementia in Long-Term Care

I have been involved in the care and study of people with brain diseases, particularly dementias, for my entire career. For 20 years, I was the Director of Psychiatry at a public long-term care facility with more than 600 beds. Powerful psychotropic medications should not be used for patients with dementia unless all other options have been proven to be ineffective, but we have created a problem in the last generation or two in which the instinct of responsible physicians is to reach first for a prescription. That’s how they’ve been trained, that’s how they think, and it’s the path of least resistance.

Psychotropic medications, particularly the antipsychotics, can achieve a short-term apparently desirable effect, which is essentially that the person becomes quiet and less disruptive. I and others have done considerable research on the effects of psychotropics, including quite a few of the antipsychotics, in the nursing home as well as in other settings. For instance, the CATIE-AD study was a federally funded study of over 400 individuals with dementia and agitation, aggression, or psychosis for which they received an antipsychotic or placebo. The study showed that, for the most part, the antipsychotics did not help. A large number of people experienced adverse effects without being helped; a small number of people were helped without being hurt; and a few had both positive and negative effects.

I think the CATIE-AD results conform with the main idea of a December 2014 NPR story on the use of antipsychotics in nursing homes, which is that, for the most part, these agents are unlikely to be helpful and are likely to confer adverse effects. I would not argue, however, that we should never use them, and, in fact, federal regulations don’t exactly say that. The federal regulations say to try to reduce or stop the medication or prove that it’s beneficial or necessary, which is a good mindset. I submit that any position that suggests that the solution is black or white is incorrect.

While widespread use of antipsychotics or other psychotropics in nursing homes is poor medicine and not evidence-based, I wouldn’t say we must never use them because sometimes you really have no alternative. Individualized care planning means just that, and, for some individuals, medication ends up being the best solution. But that shouldn’t be the starting point, except in emergencies.

The American Psychiatric Association treatment guidelines for Alzheimer’s disease and other dementias stress the importance of informing the person responsible for the welfare of the individual with dementia about all of the potential pros and cons of any medication, including the black box warnings associated with antipsychotics and the elderly. We consider it mandatory that that communication is provided, and the fact that informed consent was given is to be communicated in the documented record.

Meta-analyses indicate that anti-dementia therapies, the cholinesterase inhibitors and/or memantine, alleviate neuropsychiatric symptoms in persons with dementia, and, in terms of medication, most guidelines consider those drugs the mainstay of treatment. They seem to be effective at reducing milder forms of neuropsychiatric signs and symptoms and may be able to delay the emergence of more severe symptoms. They are probably not very effective once symptoms are severe, but proactive use of these medicines, where appropriate, may mitigate some of these problems in the long run.

Research shows that anticonvulsants, which were in vogue for a while, and benzodiazepines really don’t seem to help and primarily confer adverse events. On the other hand, recent evidence suggests that non-antipsychotic medicines like certain antidepressants, for instance citalopram, may be effective in relieving some forms of agitation, although side effects need to be taken into account as well. So, antipsychotics are the most potent but probably the most dangerous medications to use in patients with dementia. First-line medication would be the anti-dementia agents. Second-line treatment would be selective use of certain antidepressants. Anticonvulsants don’t seem to be effective, and antipsychotics are a choice of last resort. Behavioral interventions are crucial and are the subject of my next blog entry.

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.”

What Does Accountable Care Mean for Early Career Psychiatrists?

We are in the midst of a shift in the framework of health care delivery in America. Currently, most health care professionals in America are reimbursed for care provided, whether that service is for acute illness or preventive care, and reimbursement comes from the patient’s pocket, the insurance company, or the government. This model incentivizes health care providers to perform high-cost procedures and care for acute illness rather than provide preventive care and care for chronic illness.

A new model is emerging in the form of the Accountable Care Organization (ACO) and is often described as “population health care.” ACOs care for a population of patients with a fixed amount of reimbursement per member for a fixed amount of time. In an editorial in the October 30, 2014, issue of the New England Journal of Medicine, Dr Lawrence Casalino described the central goal of the ACO program as improving the value of care provided, defined by improved quality at a reduced cost. Dr Casalino also elaborated on potential pitfalls that may hinder development of the ACO movement and skewed motives that may hamper increase in true value of care provided. In the same issue, Song et al and McWilliams et al described the experiences of some of the pioneering ACOs, and, broadly speaking, these studies showed an improvement in quality and reduction in cost.

What will this movement mean for early career psychiatrists? Along with other fields, we will increasingly be required to demonstrate the quality of care that we provide. While providing high-quality care has always been paramount in medicine, how do we demonstrate that we are doing this? Using measurement-based care systems and demonstrating adherence to treatment guidelines are two ways to systematically measure quality of care in psychiatry.

I recommend that early career psychiatrists familiarize themselves with outcomes measures that can be implemented in routine clinical care. In the clinic, we ask our patients to tell us, for example, about their mood over the past 3 months. However mood, like pain, is difficult to remember accurately. When I introduce outcomes measures to my patients, I say that this measure will help both of us recall the specifics of symptoms at certain time points in the course of treatment, which will give us data to use in individualized treatment decisions.

At Penn State Psychiatry, we are implementing a systematic program of diagnostic and outcomes measurements to enhance clinical care and quality programs. Health care organizations will be increasingly interested in these kinds of data, as objective outcomes data can be collected in the aggregate to show outcomes by treatment provider or treatment setting.

Measurement-based care in psychiatry has been recommended by experts and called for in APA Practice Guidelines. Familiarity with published treatment guidelines issued through professional organizations or government health care systems abroad (eg, American Psychiatric Association, British Association for Psychopharmacology, Canadian Network for Mood and Anxiety Treatments, National Institute for Health and Clinical Excellence) is crucial for understanding the standard of care and for measuring one’s own treatment efficacy. Health care is changing, and being able to demonstrate quality of care will be increasingly important in psychiatry as in all of medicine.

Financial disclosure: Dr Saunders is a consultant for Profiles in Knowledge.

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