TBD Meeting (4259-17)

 

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

Worley_Linda_2_Nashville_web.jpg

Dr. Worley’s immediate response was to go home and “collapse into anguished sobs,” she said in an interview. Her ultimate response, however, was to change tack, as a sailor does to make the most of how the wind is blowing. “When I told my husband I couldn’t manage and felt as though I was capsizing, he told me to ‘reef in my sails,’ ” she said, describing the technique sailors use to reduce their exposure to dangerously strong winds. “That was the day my Smooth Sailing Life nautical metaphor first crystallized.”

Over the decades of an academic medical career complete with tenure, and dozens of published articles and book chapters, Dr. Worley has developed a system for achieving success while avoiding burnout, based on nautical references. In a session cofacilitated by Cynthia M. Stonnington, MD, chair of psychiatry and psychology at the Mayo Clinic’s campus in Scottsdale, Ariz., Dr. Worley presented her tips for self-care at the annual meeting of the American College of Psychiatrists.

“I use the nautical framework as a bio-psycho-social-spiritual model,” Dr. Worley said in an interview. “I teach it to medical students; I teach it to residents; I teach it to distressed physicians. I even teach it to patients when I am explaining a framework for a necessary treatment approach. With sailing, you have to stay in balance. That’s the same with taking good care of ourselves so we are less likely to get sick physically and mentally,” said Dr. Worley, who commutes to Nashville, Tenn., several times a year as part of her appointment as an adjunct professor of medicine at Vanderbilt University.

Her “Smooth Sailing Life” seminars have evolved over the past 20 years and are rooted in her training in psychosomatic medicine, which she said emphasizes the complexity of the entire person. “It’s about the biology and about the emotions, and the bridge between them,” according to Dr. Worley, who has a website, SmoothSailingLife.com, and is working on a book aimed at helping to meet what she said has been a steadily growing thirst for her approach to developing resilience.

“I am not studying anyone, but I am helping people to self-diagnose. I teach people how to avoid having to see a psychiatrist or a mental health provider but also to feel good about reaching out for help when necessary,” she said. “Life is far too short to suffer needlessly.”

In the interview, Dr. Worley said she adapts her presentations to the venue and the time allowed. Key aspects of her system include:

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

 

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

Worley_Linda_2_Nashville_web.jpg

Dr. Worley’s immediate response was to go home and “collapse into anguished sobs,” she said in an interview. Her ultimate response, however, was to change tack, as a sailor does to make the most of how the wind is blowing. “When I told my husband I couldn’t manage and felt as though I was capsizing, he told me to ‘reef in my sails,’ ” she said, describing the technique sailors use to reduce their exposure to dangerously strong winds. “That was the day my Smooth Sailing Life nautical metaphor first crystallized.”

Over the decades of an academic medical career complete with tenure, and dozens of published articles and book chapters, Dr. Worley has developed a system for achieving success while avoiding burnout, based on nautical references. In a session cofacilitated by Cynthia M. Stonnington, MD, chair of psychiatry and psychology at the Mayo Clinic’s campus in Scottsdale, Ariz., Dr. Worley presented her tips for self-care at the annual meeting of the American College of Psychiatrists.

“I use the nautical framework as a bio-psycho-social-spiritual model,” Dr. Worley said in an interview. “I teach it to medical students; I teach it to residents; I teach it to distressed physicians. I even teach it to patients when I am explaining a framework for a necessary treatment approach. With sailing, you have to stay in balance. That’s the same with taking good care of ourselves so we are less likely to get sick physically and mentally,” said Dr. Worley, who commutes to Nashville, Tenn., several times a year as part of her appointment as an adjunct professor of medicine at Vanderbilt University.

Her “Smooth Sailing Life” seminars have evolved over the past 20 years and are rooted in her training in psychosomatic medicine, which she said emphasizes the complexity of the entire person. “It’s about the biology and about the emotions, and the bridge between them,” according to Dr. Worley, who has a website, SmoothSailingLife.com, and is working on a book aimed at helping to meet what she said has been a steadily growing thirst for her approach to developing resilience.

“I am not studying anyone, but I am helping people to self-diagnose. I teach people how to avoid having to see a psychiatrist or a mental health provider but also to feel good about reaching out for help when necessary,” she said. “Life is far too short to suffer needlessly.”

In the interview, Dr. Worley said she adapts her presentations to the venue and the time allowed. Key aspects of her system include:

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

 

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Linda L.M. Worley, MD, was stunned when a meeting she’d requested with her supervisor to address a shortage of beds turned into a rebuke.

“You’re on the tenure track, Linda. If you want to keep your job 6 years from now, you’d best pick up the pace. You need to see 20 private patients a week, and get moving on your research and publications,” Dr. Worley remembers the supervisor saying. At the time, she was a 32-year-old mother of two, wife, academic faculty physician, and sole attending running a general hospital consultation liaison psychiatry department and the college of medicine student mental health service. She also worked as the 24/7 on-call psychiatrist for a week at a time, said Dr. Worley, now a staff psychiatrist in the Fayetteville, Ark., Veterans Health Care System of the Ozarks and chief mental health officer for South Central VA Health Care Network.

Worley_Linda_2_Nashville_web.jpg

Dr. Worley’s immediate response was to go home and “collapse into anguished sobs,” she said in an interview. Her ultimate response, however, was to change tack, as a sailor does to make the most of how the wind is blowing. “When I told my husband I couldn’t manage and felt as though I was capsizing, he told me to ‘reef in my sails,’ ” she said, describing the technique sailors use to reduce their exposure to dangerously strong winds. “That was the day my Smooth Sailing Life nautical metaphor first crystallized.”

Over the decades of an academic medical career complete with tenure, and dozens of published articles and book chapters, Dr. Worley has developed a system for achieving success while avoiding burnout, based on nautical references. In a session cofacilitated by Cynthia M. Stonnington, MD, chair of psychiatry and psychology at the Mayo Clinic’s campus in Scottsdale, Ariz., Dr. Worley presented her tips for self-care at the annual meeting of the American College of Psychiatrists.

“I use the nautical framework as a bio-psycho-social-spiritual model,” Dr. Worley said in an interview. “I teach it to medical students; I teach it to residents; I teach it to distressed physicians. I even teach it to patients when I am explaining a framework for a necessary treatment approach. With sailing, you have to stay in balance. That’s the same with taking good care of ourselves so we are less likely to get sick physically and mentally,” said Dr. Worley, who commutes to Nashville, Tenn., several times a year as part of her appointment as an adjunct professor of medicine at Vanderbilt University.

Her “Smooth Sailing Life” seminars have evolved over the past 20 years and are rooted in her training in psychosomatic medicine, which she said emphasizes the complexity of the entire person. “It’s about the biology and about the emotions, and the bridge between them,” according to Dr. Worley, who has a website, SmoothSailingLife.com, and is working on a book aimed at helping to meet what she said has been a steadily growing thirst for her approach to developing resilience.

“I am not studying anyone, but I am helping people to self-diagnose. I teach people how to avoid having to see a psychiatrist or a mental health provider but also to feel good about reaching out for help when necessary,” she said. “Life is far too short to suffer needlessly.”

In the interview, Dr. Worley said she adapts her presentations to the venue and the time allowed. Key aspects of her system include:

• Care for your yacht, which is the body, including the brain. “You only get one, and if you’re going to have a chance of winning the regatta, you have to take care of it. This means getting good sleep, nutrition, exercise, preventive care, rest, and rejuvenation, including vacation,” Dr. Worley said.

• Chart your course; have a navigational plan that includes your life goals and aspirations. Identify and rely upon “landmarks,” such as being a good spouse, mother, physician, or friend for the most authentic definition of personal success. “These are like buoys that keep us sailing in the right direction,” she said.

• Reef in your sails, meaning mind the “winds that come at us from every side,” she said. This includes triaging tasks and not letting perfectionism get in the way. “Perfectionists take too long to tack; they don’t know when it’s time to turn in the other direction,” she said. “If you want to finish the race, you have to do the best you can in the time you have.” This was the lesson Dr. Worley said she learned that day when she was a young physician feeling overwhelmed.

• Empty your bilge, the nautical term for removing waste water from within the hull. Dr. Worley uses this as a metaphor for identifying and expressing negative emotions of fear, anxiety, sadness, and frustration. “These vital emotions are giving us important messages. It is important to recognize that they are present. Name and accept them, and understand what they are trying to tell us. Is it a symptom of an underlying illness that needs treatment? A conflict in a relationship? A need not being met? Are you living your deepest values? Express the emotions and sort through the best response,” she said. “It’s all part of emotional intelligence.”

• Keep an even keel, which is Dr. Worley’s way of stating the importance of being connected to love and to living your deepest values. “The keel is your character, your connection to meaning, a spiritual connection. In medicine, we shy away from that. I have only lately ventured into talking about this,” she said, noting that this connection can come in numerous ways, such as meditation, and being in nature or with animals. “It’s very personal. It’s hard to quantify, but I have witnessed it and its healing power within the therapeutic alliance.”

 

In break-out sessions during her well-attended talk at the meeting, Dr. Worley listened as psychiatrists of all levels of experience and responsibility, ranging from medical directors to those in private community practice, shared the kinds of concerns she said she often encounters in her role as a core faculty member of the Program for Distressed Physicians at the Vanderbilt Center for Professional Health.

“Changes in medicine have been so frustrating; physicians are at their wits’ end. We don’t recruit people into medicine because they have a skill set for expressing their emotions, or taking care of themselves, or dealing with conflict,” she said. “That’s okay. They can learn it.”

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Failing to see depression as a chronic condition that needs to be managed has hampered the ability of psychiatry to help patients with the mood disorder, according to the principal investigator of a recently published prospective study on the most refractory of depression cases.

“The majority of research [in our field] has been on how we manage acute episodes of depression. But, these are chronic, often lifelong conditions. We need to pay attention to that and come up with solutions,” said Scott T. Aaronson, MD, program chair of this year’s annual meeting of the American College of Psychiatrists, in an interview.

125139_Aaronson_Scott_BALT_web.jpg

For Dr. Aaronson, who also directs clinical research at the Sheppard Pratt Health System in Baltimore, such solutions would include basing depression staging on the oncology model to help determine treatment algorithms. He said that he also would like to see the expanded use of electrical current therapies and trial designs that are more inclusive, with clinical endpoints that have lower thresholds than are typically used now.

“There are people who have these terrible depressions, that, even if you could get them 25% better over the course of years instead of 75% better for just a few months, they’d probably have a much better prognosis and a better quality of life. We need to pay attention to that and think of a longer horizon than we currently do,” Dr. Aaronson said.

During a scientific session at the meeting, he presented data from a 5-year, observational registry study, conducted in nearly 800 people with severe treatment-resistant depression – a population for whom no current evidence-based treatments exists – showing that adjunctive vagus nerve stimulation (VNS) had superior outcomes and mortality, compared with treatment as usual (Am J Psychiatry. 2017 Mar 31. doi: 10.1176/appi.ajp.2017.16010034).

Between January 2006 and May 2015, the multicenter study enrolled adults with unremitting unipolar or bipolar depression lasting at least 2 years. It also enrolled adults who had experienced three or more depressive episodes and had failed four or more depression treatments, including electroconvulsive therapy (ECT). People with a history of psychosis or rapid-cycling bipolar disorder were excluded. One cohort came from a patient registry designed as a postmarketing surveillance study stipulated by the Food and Drug Administration for the approval of the refractory depression indication for VNS. Another cohort came from a study that compared patients with refractory depression who received VNS therapy at various doses. People in the registry cohort were seen at 61 U.S. sites in different settings. Patients were assigned to treatment as usual or treatment as usual with adjunctive VNS based on their preference of a treatment arm. Often, patients’ treatment arm depended on whether implantation was available at their site or what their insurance would cover.

In all, 494 patients were in the VNS study arm, and 301 were in the treatment-as-usual arm. The FDA approved use of the pooled data. People in the dose-finding cohort all had VNS implants when they entered the study, and, unless lost to follow-up, all were observed for 60 months, regardless of the point at which they entered the study. About two-thirds of the dose-finding patients remained in the study for all 5 years, as did about half of the registry study cohort. Of those involved, 22 patients exercised their option of switching treatment arms, but their data were censored from the efficacy analysis. At baseline, the mean Montgomery-Asberg Depression Rating Scale (MADRS) score was 29.3 for the treatment-as-usual group and 33.1 for those in the VNS adjunct group. Responders were those who had a 50% or greater reduction in MADRS scores at any point post baseline.

The 5-year cumulative response to treatment rate in the adjunctive VNS group was significantly higher at 67.6%, compared with 40% in the treatment-as-usual arm (P less than .001). The cumulative percentage of first-time responders in the VNS adjunctive arm was nearly double that of the treatment-as-usual group at all follow-up points in the study, and they tended to respond by 1 year, compared with 2 years in the treatment-as-usual group (P less than .001).

A secondary efficacy endpoint was changes in the Clinical Global Impression–Improvement (CGI-I) scores. These also favored the VNS adjunctive group, which had a 75.9% cumulative CGI-I response rate, compared with a 48.6% rate in the treatment-as-usual arm (P less than .001). Scores on the Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR) were consistent with these results: The cumulative response rate in the VNS group was 64.7%, compared with 41.7% in the treatment-as-usual arm (P less than .001).

There were 15 deaths during the study, 7 in the VNS arm and 8 in the treatment-as-usual arm. There were two suicides in each arm, meaning the VNS arm, which was larger, experienced a lesser rate of suicides as the treatment-as-usual group. “This is a fairly key point,” Dr. Aaronson said in the interview.

The remission rate also was significantly higher in the adjunctive group at 43.3%, compared with 25.7% in the treatment-as-usual group (P less than .001). Differences in CGI-I and QIDS-SR scores also were statistically significant and were both higher in the VNS adjunct group, with cumulative response rates from baseline CGI-I scores of 49.7% vs. 21.4%, and changes in QIDS-SR scores of 40.4% vs. 25.0% (P less than .001).

Yet, these statistics do not describe the full potential affect of adjunctive VNS on refractory depression, according to Dr. Aaronson. “There were people in this study who did not meet the endpoint but who were no longer suicidal. Some [reported that they] could now just enjoy riding their bicycle,” he said. “If you asked them, ‘Did they think participating was worthwhile?’ they would tell you there was no question about it. Small differences can be incredibly meaningful for these folks. We need to rethink what success means when we treat chronic depression.”

In addition to higher mean depression rating scores at baseline, those in the VNS group also had higher rates of psychiatric hospitalizations and suicide attempts, suggesting more severe illness in this group. However, it is the fact that this group, with its higher response rate overall, also had higher baseline rates of exposure to ECT that excited Dr. Aaronson the most about the study.

A subanalysis showed that 58.7% of the adjunct VNS group and 36.2% of the treatment-as-usual arm had all had at least seven right lateral treatments of ECT, typically an exclusionary criterion in depression treatment trials. For patients in the VNS arm who previously had responded to ECT, the cumulative response rate at 5 years, based on MADRS scores, was 71.3%, compared with 56.9% of those who had responded to ECT in the treatment-as-usual group, a statistically significant difference (P less than .006). Further, a significant difference in response was recorded at 9 months and then sustained throughout the study.

For the ECT nonresponders in the VNS arm, the response rate in this study was 59.6%, compared with 34.1% for the ECT nonresponders who were receiving treatment as usual (P less than .001). Statistical separation of the two arms began after about 2 years and continued throughout the study.

“This is my personal, favorite part,” Dr. Aaronson said in the interview. “We don’t consider ECT very much, but it is, without question, one of the single most effective acute treatments we have in all of psychiatry for depression. The problem is that, for the majority who respond to it, they are sick again within 6 months. The point here is that, if you’ve ever responded to anything, including ECT, we now have a marker for who will respond to VNS.”

In part because VNS is a chronic, and comparatively less expensive, treatment, the study also has implications for patients on maintenance ECT, Dr. Aaronson said. “Wouldn’t it be terrific if I could offer them VNS rather than continuous ECT, which I worry in the long run can be hard on brains and which is expensive and inconvenient?”

More than one-third of people diagnosed with depression have the treatment-resistant type, the standard definition of which is that a person previously has failed two or more treatments. In this patient population, between 10% and 15% will go on to fail at least four treatments, Dr. Aaronson said.

Although previous failure at least 4 previous depression treatment regimens was one of the inclusion criteria in this study, the VNS population had failed an average of 8.2 previous treatments, compared with 7.3 in the treatment-as-usual arm. These data, together with the subanalysis data on ECT responders, make a compelling case for staging depression, Dr. Aaronson said.

He said, he believes that, with more study and differently structured trials, it can be demonstrated that there also should be a clinical diagnosis of “severe” treatment-resistant depression.

Dr. Aaronson and his colleagues are currently seeking funding to conduct a national study that is randomly controlled using VNS or a sham treatment. Once efficacy data are sufficient, making the case for staging depression will be easier, Dr. Aaronson said.

“I am a firm believer that we should look at psychiatric illnesses the same way we do cancers – using levels of severity,” he said. “The neat thing about [these data on] VNS is that it gives me the bully pulpit to start preaching that gospel.”

Dr. Aaronson’s relevant disclosures include Genomind, LivaNova, Neuronetics, Otsuka, Sunovion, and Takeda.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Failing to see depression as a chronic condition that needs to be managed has hampered the ability of psychiatry to help patients with the mood disorder, according to the principal investigator of a recently published prospective study on the most refractory of depression cases.

“The majority of research [in our field] has been on how we manage acute episodes of depression. But, these are chronic, often lifelong conditions. We need to pay attention to that and come up with solutions,” said Scott T. Aaronson, MD, program chair of this year’s annual meeting of the American College of Psychiatrists, in an interview.

125139_Aaronson_Scott_BALT_web.jpg

For Dr. Aaronson, who also directs clinical research at the Sheppard Pratt Health System in Baltimore, such solutions would include basing depression staging on the oncology model to help determine treatment algorithms. He said that he also would like to see the expanded use of electrical current therapies and trial designs that are more inclusive, with clinical endpoints that have lower thresholds than are typically used now.

“There are people who have these terrible depressions, that, even if you could get them 25% better over the course of years instead of 75% better for just a few months, they’d probably have a much better prognosis and a better quality of life. We need to pay attention to that and think of a longer horizon than we currently do,” Dr. Aaronson said.

During a scientific session at the meeting, he presented data from a 5-year, observational registry study, conducted in nearly 800 people with severe treatment-resistant depression – a population for whom no current evidence-based treatments exists – showing that adjunctive vagus nerve stimulation (VNS) had superior outcomes and mortality, compared with treatment as usual (Am J Psychiatry. 2017 Mar 31. doi: 10.1176/appi.ajp.2017.16010034).

Between January 2006 and May 2015, the multicenter study enrolled adults with unremitting unipolar or bipolar depression lasting at least 2 years. It also enrolled adults who had experienced three or more depressive episodes and had failed four or more depression treatments, including electroconvulsive therapy (ECT). People with a history of psychosis or rapid-cycling bipolar disorder were excluded. One cohort came from a patient registry designed as a postmarketing surveillance study stipulated by the Food and Drug Administration for the approval of the refractory depression indication for VNS. Another cohort came from a study that compared patients with refractory depression who received VNS therapy at various doses. People in the registry cohort were seen at 61 U.S. sites in different settings. Patients were assigned to treatment as usual or treatment as usual with adjunctive VNS based on their preference of a treatment arm. Often, patients’ treatment arm depended on whether implantation was available at their site or what their insurance would cover.

In all, 494 patients were in the VNS study arm, and 301 were in the treatment-as-usual arm. The FDA approved use of the pooled data. People in the dose-finding cohort all had VNS implants when they entered the study, and, unless lost to follow-up, all were observed for 60 months, regardless of the point at which they entered the study. About two-thirds of the dose-finding patients remained in the study for all 5 years, as did about half of the registry study cohort. Of those involved, 22 patients exercised their option of switching treatment arms, but their data were censored from the efficacy analysis. At baseline, the mean Montgomery-Asberg Depression Rating Scale (MADRS) score was 29.3 for the treatment-as-usual group and 33.1 for those in the VNS adjunct group. Responders were those who had a 50% or greater reduction in MADRS scores at any point post baseline.

The 5-year cumulative response to treatment rate in the adjunctive VNS group was significantly higher at 67.6%, compared with 40% in the treatment-as-usual arm (P less than .001). The cumulative percentage of first-time responders in the VNS adjunctive arm was nearly double that of the treatment-as-usual group at all follow-up points in the study, and they tended to respond by 1 year, compared with 2 years in the treatment-as-usual group (P less than .001).

A secondary efficacy endpoint was changes in the Clinical Global Impression–Improvement (CGI-I) scores. These also favored the VNS adjunctive group, which had a 75.9% cumulative CGI-I response rate, compared with a 48.6% rate in the treatment-as-usual arm (P less than .001). Scores on the Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR) were consistent with these results: The cumulative response rate in the VNS group was 64.7%, compared with 41.7% in the treatment-as-usual arm (P less than .001).

There were 15 deaths during the study, 7 in the VNS arm and 8 in the treatment-as-usual arm. There were two suicides in each arm, meaning the VNS arm, which was larger, experienced a lesser rate of suicides as the treatment-as-usual group. “This is a fairly key point,” Dr. Aaronson said in the interview.

The remission rate also was significantly higher in the adjunctive group at 43.3%, compared with 25.7% in the treatment-as-usual group (P less than .001). Differences in CGI-I and QIDS-SR scores also were statistically significant and were both higher in the VNS adjunct group, with cumulative response rates from baseline CGI-I scores of 49.7% vs. 21.4%, and changes in QIDS-SR scores of 40.4% vs. 25.0% (P less than .001).

Yet, these statistics do not describe the full potential affect of adjunctive VNS on refractory depression, according to Dr. Aaronson. “There were people in this study who did not meet the endpoint but who were no longer suicidal. Some [reported that they] could now just enjoy riding their bicycle,” he said. “If you asked them, ‘Did they think participating was worthwhile?’ they would tell you there was no question about it. Small differences can be incredibly meaningful for these folks. We need to rethink what success means when we treat chronic depression.”

In addition to higher mean depression rating scores at baseline, those in the VNS group also had higher rates of psychiatric hospitalizations and suicide attempts, suggesting more severe illness in this group. However, it is the fact that this group, with its higher response rate overall, also had higher baseline rates of exposure to ECT that excited Dr. Aaronson the most about the study.

A subanalysis showed that 58.7% of the adjunct VNS group and 36.2% of the treatment-as-usual arm had all had at least seven right lateral treatments of ECT, typically an exclusionary criterion in depression treatment trials. For patients in the VNS arm who previously had responded to ECT, the cumulative response rate at 5 years, based on MADRS scores, was 71.3%, compared with 56.9% of those who had responded to ECT in the treatment-as-usual group, a statistically significant difference (P less than .006). Further, a significant difference in response was recorded at 9 months and then sustained throughout the study.

For the ECT nonresponders in the VNS arm, the response rate in this study was 59.6%, compared with 34.1% for the ECT nonresponders who were receiving treatment as usual (P less than .001). Statistical separation of the two arms began after about 2 years and continued throughout the study.

“This is my personal, favorite part,” Dr. Aaronson said in the interview. “We don’t consider ECT very much, but it is, without question, one of the single most effective acute treatments we have in all of psychiatry for depression. The problem is that, for the majority who respond to it, they are sick again within 6 months. The point here is that, if you’ve ever responded to anything, including ECT, we now have a marker for who will respond to VNS.”

In part because VNS is a chronic, and comparatively less expensive, treatment, the study also has implications for patients on maintenance ECT, Dr. Aaronson said. “Wouldn’t it be terrific if I could offer them VNS rather than continuous ECT, which I worry in the long run can be hard on brains and which is expensive and inconvenient?”

More than one-third of people diagnosed with depression have the treatment-resistant type, the standard definition of which is that a person previously has failed two or more treatments. In this patient population, between 10% and 15% will go on to fail at least four treatments, Dr. Aaronson said.

Although previous failure at least 4 previous depression treatment regimens was one of the inclusion criteria in this study, the VNS population had failed an average of 8.2 previous treatments, compared with 7.3 in the treatment-as-usual arm. These data, together with the subanalysis data on ECT responders, make a compelling case for staging depression, Dr. Aaronson said.

He said, he believes that, with more study and differently structured trials, it can be demonstrated that there also should be a clinical diagnosis of “severe” treatment-resistant depression.

Dr. Aaronson and his colleagues are currently seeking funding to conduct a national study that is randomly controlled using VNS or a sham treatment. Once efficacy data are sufficient, making the case for staging depression will be easier, Dr. Aaronson said.

“I am a firm believer that we should look at psychiatric illnesses the same way we do cancers – using levels of severity,” he said. “The neat thing about [these data on] VNS is that it gives me the bully pulpit to start preaching that gospel.”

Dr. Aaronson’s relevant disclosures include Genomind, LivaNova, Neuronetics, Otsuka, Sunovion, and Takeda.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Failing to see depression as a chronic condition that needs to be managed has hampered the ability of psychiatry to help patients with the mood disorder, according to the principal investigator of a recently published prospective study on the most refractory of depression cases.

“The majority of research [in our field] has been on how we manage acute episodes of depression. But, these are chronic, often lifelong conditions. We need to pay attention to that and come up with solutions,” said Scott T. Aaronson, MD, program chair of this year’s annual meeting of the American College of Psychiatrists, in an interview.

125139_Aaronson_Scott_BALT_web.jpg

For Dr. Aaronson, who also directs clinical research at the Sheppard Pratt Health System in Baltimore, such solutions would include basing depression staging on the oncology model to help determine treatment algorithms. He said that he also would like to see the expanded use of electrical current therapies and trial designs that are more inclusive, with clinical endpoints that have lower thresholds than are typically used now.

“There are people who have these terrible depressions, that, even if you could get them 25% better over the course of years instead of 75% better for just a few months, they’d probably have a much better prognosis and a better quality of life. We need to pay attention to that and think of a longer horizon than we currently do,” Dr. Aaronson said.

During a scientific session at the meeting, he presented data from a 5-year, observational registry study, conducted in nearly 800 people with severe treatment-resistant depression – a population for whom no current evidence-based treatments exists – showing that adjunctive vagus nerve stimulation (VNS) had superior outcomes and mortality, compared with treatment as usual (Am J Psychiatry. 2017 Mar 31. doi: 10.1176/appi.ajp.2017.16010034).

Between January 2006 and May 2015, the multicenter study enrolled adults with unremitting unipolar or bipolar depression lasting at least 2 years. It also enrolled adults who had experienced three or more depressive episodes and had failed four or more depression treatments, including electroconvulsive therapy (ECT). People with a history of psychosis or rapid-cycling bipolar disorder were excluded. One cohort came from a patient registry designed as a postmarketing surveillance study stipulated by the Food and Drug Administration for the approval of the refractory depression indication for VNS. Another cohort came from a study that compared patients with refractory depression who received VNS therapy at various doses. People in the registry cohort were seen at 61 U.S. sites in different settings. Patients were assigned to treatment as usual or treatment as usual with adjunctive VNS based on their preference of a treatment arm. Often, patients’ treatment arm depended on whether implantation was available at their site or what their insurance would cover.

In all, 494 patients were in the VNS study arm, and 301 were in the treatment-as-usual arm. The FDA approved use of the pooled data. People in the dose-finding cohort all had VNS implants when they entered the study, and, unless lost to follow-up, all were observed for 60 months, regardless of the point at which they entered the study. About two-thirds of the dose-finding patients remained in the study for all 5 years, as did about half of the registry study cohort. Of those involved, 22 patients exercised their option of switching treatment arms, but their data were censored from the efficacy analysis. At baseline, the mean Montgomery-Asberg Depression Rating Scale (MADRS) score was 29.3 for the treatment-as-usual group and 33.1 for those in the VNS adjunct group. Responders were those who had a 50% or greater reduction in MADRS scores at any point post baseline.

The 5-year cumulative response to treatment rate in the adjunctive VNS group was significantly higher at 67.6%, compared with 40% in the treatment-as-usual arm (P less than .001). The cumulative percentage of first-time responders in the VNS adjunctive arm was nearly double that of the treatment-as-usual group at all follow-up points in the study, and they tended to respond by 1 year, compared with 2 years in the treatment-as-usual group (P less than .001).

A secondary efficacy endpoint was changes in the Clinical Global Impression–Improvement (CGI-I) scores. These also favored the VNS adjunctive group, which had a 75.9% cumulative CGI-I response rate, compared with a 48.6% rate in the treatment-as-usual arm (P less than .001). Scores on the Quick Inventory of Depressive Symptomatology–Self-Report (QIDS-SR) were consistent with these results: The cumulative response rate in the VNS group was 64.7%, compared with 41.7% in the treatment-as-usual arm (P less than .001).

There were 15 deaths during the study, 7 in the VNS arm and 8 in the treatment-as-usual arm. There were two suicides in each arm, meaning the VNS arm, which was larger, experienced a lesser rate of suicides as the treatment-as-usual group. “This is a fairly key point,” Dr. Aaronson said in the interview.

The remission rate also was significantly higher in the adjunctive group at 43.3%, compared with 25.7% in the treatment-as-usual group (P less than .001). Differences in CGI-I and QIDS-SR scores also were statistically significant and were both higher in the VNS adjunct group, with cumulative response rates from baseline CGI-I scores of 49.7% vs. 21.4%, and changes in QIDS-SR scores of 40.4% vs. 25.0% (P less than .001).

Yet, these statistics do not describe the full potential affect of adjunctive VNS on refractory depression, according to Dr. Aaronson. “There were people in this study who did not meet the endpoint but who were no longer suicidal. Some [reported that they] could now just enjoy riding their bicycle,” he said. “If you asked them, ‘Did they think participating was worthwhile?’ they would tell you there was no question about it. Small differences can be incredibly meaningful for these folks. We need to rethink what success means when we treat chronic depression.”

In addition to higher mean depression rating scores at baseline, those in the VNS group also had higher rates of psychiatric hospitalizations and suicide attempts, suggesting more severe illness in this group. However, it is the fact that this group, with its higher response rate overall, also had higher baseline rates of exposure to ECT that excited Dr. Aaronson the most about the study.

A subanalysis showed that 58.7% of the adjunct VNS group and 36.2% of the treatment-as-usual arm had all had at least seven right lateral treatments of ECT, typically an exclusionary criterion in depression treatment trials. For patients in the VNS arm who previously had responded to ECT, the cumulative response rate at 5 years, based on MADRS scores, was 71.3%, compared with 56.9% of those who had responded to ECT in the treatment-as-usual group, a statistically significant difference (P less than .006). Further, a significant difference in response was recorded at 9 months and then sustained throughout the study.

For the ECT nonresponders in the VNS arm, the response rate in this study was 59.6%, compared with 34.1% for the ECT nonresponders who were receiving treatment as usual (P less than .001). Statistical separation of the two arms began after about 2 years and continued throughout the study.

“This is my personal, favorite part,” Dr. Aaronson said in the interview. “We don’t consider ECT very much, but it is, without question, one of the single most effective acute treatments we have in all of psychiatry for depression. The problem is that, for the majority who respond to it, they are sick again within 6 months. The point here is that, if you’ve ever responded to anything, including ECT, we now have a marker for who will respond to VNS.”

In part because VNS is a chronic, and comparatively less expensive, treatment, the study also has implications for patients on maintenance ECT, Dr. Aaronson said. “Wouldn’t it be terrific if I could offer them VNS rather than continuous ECT, which I worry in the long run can be hard on brains and which is expensive and inconvenient?”

More than one-third of people diagnosed with depression have the treatment-resistant type, the standard definition of which is that a person previously has failed two or more treatments. In this patient population, between 10% and 15% will go on to fail at least four treatments, Dr. Aaronson said.

Although previous failure at least 4 previous depression treatment regimens was one of the inclusion criteria in this study, the VNS population had failed an average of 8.2 previous treatments, compared with 7.3 in the treatment-as-usual arm. These data, together with the subanalysis data on ECT responders, make a compelling case for staging depression, Dr. Aaronson said.

He said, he believes that, with more study and differently structured trials, it can be demonstrated that there also should be a clinical diagnosis of “severe” treatment-resistant depression.

Dr. Aaronson and his colleagues are currently seeking funding to conduct a national study that is randomly controlled using VNS or a sham treatment. Once efficacy data are sufficient, making the case for staging depression will be easier, Dr. Aaronson said.

“I am a firm believer that we should look at psychiatric illnesses the same way we do cancers – using levels of severity,” he said. “The neat thing about [these data on] VNS is that it gives me the bully pulpit to start preaching that gospel.”

Dr. Aaronson’s relevant disclosures include Genomind, LivaNova, Neuronetics, Otsuka, Sunovion, and Takeda.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.

“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.

Drescher_Jack_NYC_web.jpg

According to a 2012 task force report of the American Psychiatric Association, no expert clinical consensus exists on the treatment of gender dysphoria in prepubescent children. However, there is some overlap in the prevailing approaches, said Dr. Drescher, who served as a member of the American Psychiatric Association’s DSM-5 Work Group on Sexual and Gender Identity Disorders.

The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.

“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”

Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.

This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.

“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”

An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.

A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.

Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.

The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.

In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”

Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.

Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”

 

Gender-related glossary of terms

"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.

To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
 
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
 
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
 
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).  
 
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
 
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
 
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
 
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
 
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
 
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
 
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
 
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.  
 
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
 
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
 
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.  
 
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.  
 
Transman:  A person who transitions from a female sex assignment to become male.
 
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
 
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
 
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.

“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.

Drescher_Jack_NYC_web.jpg

According to a 2012 task force report of the American Psychiatric Association, no expert clinical consensus exists on the treatment of gender dysphoria in prepubescent children. However, there is some overlap in the prevailing approaches, said Dr. Drescher, who served as a member of the American Psychiatric Association’s DSM-5 Work Group on Sexual and Gender Identity Disorders.

The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.

“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”

Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.

This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.

“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”

An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.

A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.

Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.

The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.

In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”

Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.

Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”

 

Gender-related glossary of terms

"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.

To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
 
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
 
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
 
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).  
 
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
 
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
 
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
 
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
 
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
 
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
 
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
 
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.  
 
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
 
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
 
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.  
 
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.  
 
Transman:  A person who transitions from a female sex assignment to become male.
 
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
 
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
 
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – The treatment of preadolescents who present with gender questions is often complicated by the absence of evidence-based data on who is most likely to remain gender dysphoric into adulthood and who is not, an expert said at the annual meeting of the American College of Psychiatrists.

“There are some [clinicians] who believe they can predict who will persist and who will not. But they have not published, to my satisfaction, a way to show anyone else how to tell the difference,” said Jack Drescher, MD, a member of the World Health Organization’s (WHO’s) Working Group on the Classification of Sexual Disorders and Sexual Health and clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla.

Drescher_Jack_NYC_web.jpg

According to a 2012 task force report of the American Psychiatric Association, no expert clinical consensus exists on the treatment of gender dysphoria in prepubescent children. However, there is some overlap in the prevailing approaches, said Dr. Drescher, who served as a member of the American Psychiatric Association’s DSM-5 Work Group on Sexual and Gender Identity Disorders.

The WHO working group was tasked with categorizing sex and gender diagnoses in the forthcoming International Classification of Diseases (ICD-11). Dr. Drescher said that he and his fellow WHO working group members have identified at least three discrete transgender populations.

“There are persisters, desisters, and those who first develop gender dysphoria in adolescence and adulthood,” he said. “It would be a clinical mistake to think that there is a seamless transition from childhood gender dysphoria into adolescent and adult gender dysphoria.”

Dr. Drescher said that he believes the Dutch model for treating younger children diagnosed with what is interchangeably referred to as gender dysphoria or gender variance demonstrates the greatest sensitivity to how fluid the situation can be for many of these children. The absence of biomarkers for dysphoria that will persist into adulthood and the finding that a minority of prepubescent gender dysphoria diagnoses persist into adolescence inform the Dutch approach.

This approach, which originated at the VU University Medical Center Amsterdam, is based on 2 decades of research and practice. It assumes that it is better not to actively transition a child socially but to remain neutral to the way in which the child expresses gender identity. If children persist into late adolescence in this model, they are assisted in transitioning. If not, they are supported socially as they adjust to their natal gender. Puberty may sometimes have to be suppressed until the time one of the two paths has been decided.

“In my opinion, it is the most conservative approach,” Dr. Drescher said of the Dutch model. “They are the most cognizant of how much we don’t know, and they do a lot of good research.”

An approach originating at the Child and Adolescent Gender Center Clinic, which is affiliated with the University of California, San Francisco, supports a child socially into a cross-gendered role without medical or surgical intervention but also suppresses puberty. This method is based on the presumption of an adult transgender outcome, despite the absence of a way to predict results, said Dr. Drescher, who also cautions about the iatrogenic effects of such a presumption. “It takes a lot of work to socially transition a child in one direction. It would take a lot to transition back in the other direction, and there is no good empirical data as to whether this is entirely a benign process,” he said.

A third method originated in Toronto at the Centre for Addiction and Mental Health. This method actively discourages a child’s atypical gender interests and views transsexualism as an undesirable outcome that can be prevented, despite what Dr. Drescher said is a complete lack of evidence to either support or refute this claim. This method largely has been abandoned, in part since Ontario and five U.S. states and the District of Columbia have passed laws banning efforts to change a minor’s sexual orientation or gender identity. This method does have puberty suppression in children whose gender dysphoria appears to be persisting into adolescence in common with the other two.

Dr. Drescher said puberty suppression has helped decrease the levels of anxiety, depression, and suicidal ideation typically associated with this cohort. Postponing the development of secondary sexual characteristics gives those who ultimately will desist from their dysphoria more time to let it run its course. The Dutch first initiated this procedure 2 decades ago and have shown that any possible future side effects are outweighed by the psychosocial advantages it provides in the present.

The clinical view of gender dysphoria probably will get a jolt in 2018 upon publication of the ICD-11. In an interview, Dr. Drescher said that, if the condition is no longer categorized by the WHO as a mental disorder and is instead called “gender incongruence” in a chapter dedicated to gender and sexuality issues as currently planned, “it is likely the [American Psychiatric Association] will follow suit and remove gender dysphoria from the DSM. However, I don’t know how long that will take,” he said.

In his presentation, Dr. Drescher said that the causes for gender dysphoria remain unknown, as do the ways in which gender identity develops. It is also unclear how biological, psychosocial, and environmental factors affect gender dysphoria. What is clear, he said, is that “we have to rethink our developmental literature.”

Meanwhile, although gender dysphoria affects a relatively small percentage of the population – less than 1% of “nonreferred” children and adolescents, according to the DSM-5 – the number of prepubescent children presenting to gender clinics is on the rise. This increase might be driven more by social forces than by scientific ones. Dr. Drescher made an anecdotal observation during the presentation that more children are presenting to gender clinics already socially transitioned by their parents than there are children in the research literature on persisters and desisters.

Dr. Drescher recalled in the interview that, during the public comment period for the DSM-5, gender dysphoria elicited the third most responses, compared with other diagnoses, despite its rarity as a condition. “Interest in the subject far outweighs its prevalence.”

 

Gender-related glossary of terms

"There are so many moving parts to our understanding of gender," said Jack Drescher, MD, during a plenary session at the annual meeting of the American College of Psychiatrists. For that reason, "language is very important" when addressing children who might have questions about their gender identity, he said.

To help establish as much clarity as possible when discussing gender in the clinical setting, Dr. Drescher offered the following glossary of terms. These are not listed alphabetically but in a stepwise fashion aimed at leading to a clearer understanding of successive terms.
 
Sex: The biological attributes of being male or female. This includes sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.
 
Gender: The public - and typically the legal - recognition of one's lived role as a boy, girl, man, woman or of other biological factors in combination with psychosocial factors that are seen as contributing to identity development.
 
Sexual orientation: A person's erotic response tendency or sexual attractions, either directed toward individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual).  
 
Gender identity: Often an independent variable from sexual orientation, this refers to how an individual identifies as either male, female, or, in some cases, some other category.
 
Gender assignment: The natal presentation as either male or female. The historical terms are "biological male" or "biological female"; also occasionally known as "birth assigned male" or "birth assigned female."
 
Gender atypical: The somatic features or behaviors not statistically typical in individuals with the same assigned gender in a given society or era.
 
Gender nonconforming: Typically used as an alternative descriptive term for "gender atypical".
 
Gender dysphoria: The conflict between a person's assigned gender and that person's gender identity and expression; replaced "gender identity disorder" in the DSM-5.
 
Gender variant: Often used by those who are concerned the term "gender dysphoria" will unnecessarily pathologize a child.
 
Gender expression: How an individual demonstrates gender to others, including by way of dress, behavior, and appearance. Increasingly, the term is used in antidiscrimination documents.
 
Desister: Prepubescent children who present with gender dysphoria but who do not become transgender adults.  
 
Persister: This refers to children who present with gender dysphoria and progress to a transgender adulthood.
 
Gender reassignment: An official - and often legal - change of gender by way of cross-sex endocrine therapy and/or gender reassignment surgery.
 
Transsexual: An individual who modifies the body via endocrine and/or surgical means to conform with gender identity either partially or completely.  
 
Transwoman: A person, such as Caitlyn Jenner, who transitions from a male sex assignment to become female.  
 
Transman:  A person who transitions from a female sex assignment to become male.
 
Transgender: The "T" in the acronym LGBT; the popular - not scientific - inclusive term for those whose gender identity, gender expression, or behavior does not conform to that which is typically associated with the natal sex assignment.
 
Cisgender: From the Latin for "on the same side"; used in the transgender community to describe those whose gender identities align with their natal assignment.
 
Gender beliefs: Used to refer to the implicit, typically binary, cultural views on the "essential" qualities of men and women.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Inflammation is inextricably linked to depression in a subset of patients who differ from other depressed patients in their responses to certain interventions, according to Charles L. Raison, MD.

“The brains of people who are depressed and who have inflammation look very different from those of people who are depressed without inflammation,” Dr. Raison said in an interview at the annual meeting of the American College of Psychiatrists. “They have different connectivity patterns, different glutaminergic patterns, different signaling. It seems that inflammatory processes change the way different parts of the brain talk to each other and seem to do so in consistent ways.”

Dr. Raison, the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families at the University of Wisconsin–Madison, told a plenary audience at the meeting: “We [psychiatrists] are so brain centric, it’s easy to forget how much the immune system drives us. It’s either like a second brain, or it is at least part of the brain.”

Raison_Charles_Madison_web.jpg

Over the years, Dr. Raison and his colleagues have observed how inflammation can interfere with mood, leading to depression in people who previously did not report or describe depressive symptoms.

In the early 2000s, Dr. Raison and others such as Andrew H. Miller, MD, a psychiatric oncologist, investigated the inflammatory response and levels of depression in people treated with interferon-alpha for hepatitis C infection (J Clin Psychiatry. 2005 Jan;66[1]:41-8). They found that more than half of people who had not reported or described depressive symptoms at baseline subsequently reported depressive symptoms. “In a nutshell, we found that interferon-alpha induces every single brain-body function associated with regular old major depression,” said Dr. Raison, also a professor of psychiatry at the university.

In another study, this one led by neuropsychosomatic specialist Dominique L. Musselman, MD, a similar cohort of hepatitis C patients assessed for baseline depression was randomly assigned to either placebo or paroxetine during the course of interferon-alpha treatment. Patients treated with placebo had a 0.24 relative risk (95% confidence interval, 0.08-0.93) of developing depression, compared with the paroxetine group (N Eng J Med. 2001;344:961-6).

The real “breakthrough” in understanding the role of inflammation in depression, Dr. Raison said, came from studies that made the association between early-life adversity, depression, and inflammation. In one particular study, Dr. Raison and colleagues found that stress-induced spikes in interleukin-6 and NF-kappaB DNA-binding were greater in patients with higher baseline levels of depression and higher levels of early life stress (Am J Psychiatry. 2006 Sep;163[9]:1630-3).

Spikes in the inflammatory response independently correlated with depression severity but not with early life stress, which Dr. Raison said suggests that adversity likely can cause inflammation – and thus predisposes people to depression, and not necessarily vice versa.

“Something about early adversity in life programs the brain-body complex to run inflammatory systems hot, probably because it’s an effective way to be ready for [a stream of] unpredictable miseries,” Dr. Raison said during the session. “Chronic, elevated inflammation [early on] seems to predict increased depression later.”

Now that the link has been established between some depression and inflammation, the next step for science is to tease out who is most likely to respond to anti-inflammatory interventions for depression, Dr. Raison said.

“Something that is just starting to emerge is that maybe the relationship between inflammation and depression is not a straight line but a U-shaped curve, such that if you have too much inflammation, you’re in trouble, and if you have too little, you’re also in trouble,” he said in the interview, citing a study he and others conducted into blocking the inflammatory response. In that study, people with major depression who were otherwise medically healthy received either three infusions of the anti-inflammatory tumor necrosis factor–alpha antagonist infliximab (5 mg/kg), or of salt water. The investigators found that placebo worked just as well as infliximab. But patients with lower levels of inflammation at baseline had the greatest improvements in their Hamilton Rating Scale for Depression scores with placebo when compared with treatment (JAMA Psychiatry. 2013 Jan;70[1]:31-41).

Data are not yet conclusive, but Dr. Raison said the field soon could use biomarkers such as levels of C-reactive protein to determine whether patients will respond to anti-inflammatories such as omega-3 essential fatty acids. “Everyone in psychiatry is desperate to find clear, unambiguous answers. We’re right on the edge, but we’re not there yet.”

Until then, Dr. Raison cautioned against the “indiscriminate” use of anti-inflammatories, lest they exacerbate patients’ depressive symptoms. “For instance, omega-3 fatty acids might actually be counterproductive in a lot of depressed people,” he said. Still, he believes that “developing and studying anti-inflammatory strategies is probably going to lead to a novel way of treating depression in some people. What is beautiful is that if these studies continue, we might actually be able – for the first time – to target a subgroup of patients for a specific treatment.”

Dr. Raison is on the scientific advisory board of the Usona Institute, a nonprofit medical research firm.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Inflammation is inextricably linked to depression in a subset of patients who differ from other depressed patients in their responses to certain interventions, according to Charles L. Raison, MD.

“The brains of people who are depressed and who have inflammation look very different from those of people who are depressed without inflammation,” Dr. Raison said in an interview at the annual meeting of the American College of Psychiatrists. “They have different connectivity patterns, different glutaminergic patterns, different signaling. It seems that inflammatory processes change the way different parts of the brain talk to each other and seem to do so in consistent ways.”

Dr. Raison, the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families at the University of Wisconsin–Madison, told a plenary audience at the meeting: “We [psychiatrists] are so brain centric, it’s easy to forget how much the immune system drives us. It’s either like a second brain, or it is at least part of the brain.”

Raison_Charles_Madison_web.jpg

Over the years, Dr. Raison and his colleagues have observed how inflammation can interfere with mood, leading to depression in people who previously did not report or describe depressive symptoms.

In the early 2000s, Dr. Raison and others such as Andrew H. Miller, MD, a psychiatric oncologist, investigated the inflammatory response and levels of depression in people treated with interferon-alpha for hepatitis C infection (J Clin Psychiatry. 2005 Jan;66[1]:41-8). They found that more than half of people who had not reported or described depressive symptoms at baseline subsequently reported depressive symptoms. “In a nutshell, we found that interferon-alpha induces every single brain-body function associated with regular old major depression,” said Dr. Raison, also a professor of psychiatry at the university.

In another study, this one led by neuropsychosomatic specialist Dominique L. Musselman, MD, a similar cohort of hepatitis C patients assessed for baseline depression was randomly assigned to either placebo or paroxetine during the course of interferon-alpha treatment. Patients treated with placebo had a 0.24 relative risk (95% confidence interval, 0.08-0.93) of developing depression, compared with the paroxetine group (N Eng J Med. 2001;344:961-6).

The real “breakthrough” in understanding the role of inflammation in depression, Dr. Raison said, came from studies that made the association between early-life adversity, depression, and inflammation. In one particular study, Dr. Raison and colleagues found that stress-induced spikes in interleukin-6 and NF-kappaB DNA-binding were greater in patients with higher baseline levels of depression and higher levels of early life stress (Am J Psychiatry. 2006 Sep;163[9]:1630-3).

Spikes in the inflammatory response independently correlated with depression severity but not with early life stress, which Dr. Raison said suggests that adversity likely can cause inflammation – and thus predisposes people to depression, and not necessarily vice versa.

“Something about early adversity in life programs the brain-body complex to run inflammatory systems hot, probably because it’s an effective way to be ready for [a stream of] unpredictable miseries,” Dr. Raison said during the session. “Chronic, elevated inflammation [early on] seems to predict increased depression later.”

Now that the link has been established between some depression and inflammation, the next step for science is to tease out who is most likely to respond to anti-inflammatory interventions for depression, Dr. Raison said.

“Something that is just starting to emerge is that maybe the relationship between inflammation and depression is not a straight line but a U-shaped curve, such that if you have too much inflammation, you’re in trouble, and if you have too little, you’re also in trouble,” he said in the interview, citing a study he and others conducted into blocking the inflammatory response. In that study, people with major depression who were otherwise medically healthy received either three infusions of the anti-inflammatory tumor necrosis factor–alpha antagonist infliximab (5 mg/kg), or of salt water. The investigators found that placebo worked just as well as infliximab. But patients with lower levels of inflammation at baseline had the greatest improvements in their Hamilton Rating Scale for Depression scores with placebo when compared with treatment (JAMA Psychiatry. 2013 Jan;70[1]:31-41).

Data are not yet conclusive, but Dr. Raison said the field soon could use biomarkers such as levels of C-reactive protein to determine whether patients will respond to anti-inflammatories such as omega-3 essential fatty acids. “Everyone in psychiatry is desperate to find clear, unambiguous answers. We’re right on the edge, but we’re not there yet.”

Until then, Dr. Raison cautioned against the “indiscriminate” use of anti-inflammatories, lest they exacerbate patients’ depressive symptoms. “For instance, omega-3 fatty acids might actually be counterproductive in a lot of depressed people,” he said. Still, he believes that “developing and studying anti-inflammatory strategies is probably going to lead to a novel way of treating depression in some people. What is beautiful is that if these studies continue, we might actually be able – for the first time – to target a subgroup of patients for a specific treatment.”

Dr. Raison is on the scientific advisory board of the Usona Institute, a nonprofit medical research firm.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Inflammation is inextricably linked to depression in a subset of patients who differ from other depressed patients in their responses to certain interventions, according to Charles L. Raison, MD.

“The brains of people who are depressed and who have inflammation look very different from those of people who are depressed without inflammation,” Dr. Raison said in an interview at the annual meeting of the American College of Psychiatrists. “They have different connectivity patterns, different glutaminergic patterns, different signaling. It seems that inflammatory processes change the way different parts of the brain talk to each other and seem to do so in consistent ways.”

Dr. Raison, the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families at the University of Wisconsin–Madison, told a plenary audience at the meeting: “We [psychiatrists] are so brain centric, it’s easy to forget how much the immune system drives us. It’s either like a second brain, or it is at least part of the brain.”

Raison_Charles_Madison_web.jpg

Over the years, Dr. Raison and his colleagues have observed how inflammation can interfere with mood, leading to depression in people who previously did not report or describe depressive symptoms.

In the early 2000s, Dr. Raison and others such as Andrew H. Miller, MD, a psychiatric oncologist, investigated the inflammatory response and levels of depression in people treated with interferon-alpha for hepatitis C infection (J Clin Psychiatry. 2005 Jan;66[1]:41-8). They found that more than half of people who had not reported or described depressive symptoms at baseline subsequently reported depressive symptoms. “In a nutshell, we found that interferon-alpha induces every single brain-body function associated with regular old major depression,” said Dr. Raison, also a professor of psychiatry at the university.

In another study, this one led by neuropsychosomatic specialist Dominique L. Musselman, MD, a similar cohort of hepatitis C patients assessed for baseline depression was randomly assigned to either placebo or paroxetine during the course of interferon-alpha treatment. Patients treated with placebo had a 0.24 relative risk (95% confidence interval, 0.08-0.93) of developing depression, compared with the paroxetine group (N Eng J Med. 2001;344:961-6).

The real “breakthrough” in understanding the role of inflammation in depression, Dr. Raison said, came from studies that made the association between early-life adversity, depression, and inflammation. In one particular study, Dr. Raison and colleagues found that stress-induced spikes in interleukin-6 and NF-kappaB DNA-binding were greater in patients with higher baseline levels of depression and higher levels of early life stress (Am J Psychiatry. 2006 Sep;163[9]:1630-3).

Spikes in the inflammatory response independently correlated with depression severity but not with early life stress, which Dr. Raison said suggests that adversity likely can cause inflammation – and thus predisposes people to depression, and not necessarily vice versa.

“Something about early adversity in life programs the brain-body complex to run inflammatory systems hot, probably because it’s an effective way to be ready for [a stream of] unpredictable miseries,” Dr. Raison said during the session. “Chronic, elevated inflammation [early on] seems to predict increased depression later.”

Now that the link has been established between some depression and inflammation, the next step for science is to tease out who is most likely to respond to anti-inflammatory interventions for depression, Dr. Raison said.

“Something that is just starting to emerge is that maybe the relationship between inflammation and depression is not a straight line but a U-shaped curve, such that if you have too much inflammation, you’re in trouble, and if you have too little, you’re also in trouble,” he said in the interview, citing a study he and others conducted into blocking the inflammatory response. In that study, people with major depression who were otherwise medically healthy received either three infusions of the anti-inflammatory tumor necrosis factor–alpha antagonist infliximab (5 mg/kg), or of salt water. The investigators found that placebo worked just as well as infliximab. But patients with lower levels of inflammation at baseline had the greatest improvements in their Hamilton Rating Scale for Depression scores with placebo when compared with treatment (JAMA Psychiatry. 2013 Jan;70[1]:31-41).

Data are not yet conclusive, but Dr. Raison said the field soon could use biomarkers such as levels of C-reactive protein to determine whether patients will respond to anti-inflammatories such as omega-3 essential fatty acids. “Everyone in psychiatry is desperate to find clear, unambiguous answers. We’re right on the edge, but we’re not there yet.”

Until then, Dr. Raison cautioned against the “indiscriminate” use of anti-inflammatories, lest they exacerbate patients’ depressive symptoms. “For instance, omega-3 fatty acids might actually be counterproductive in a lot of depressed people,” he said. Still, he believes that “developing and studying anti-inflammatory strategies is probably going to lead to a novel way of treating depression in some people. What is beautiful is that if these studies continue, we might actually be able – for the first time – to target a subgroup of patients for a specific treatment.”

Dr. Raison is on the scientific advisory board of the Usona Institute, a nonprofit medical research firm.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.

“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”

Michels_Robert_NYC_web.jpg

For much of the 20th century, psychoanalysis was the leading outpatient psychiatric therapy. Beginning in the late 1980s, its star began to fade with the rise of safer psychotropics, the outcomes of which are easier to quantify. It also takes less time to see results with drug therapy in the clinical setting, compared with the various forms of psychotherapies – some of which require three or more visits weekly.

“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”

Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.

And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.

Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.

Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”

In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”

Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.

The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.

He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”

Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”

Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.

“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”

Michels_Robert_NYC_web.jpg

For much of the 20th century, psychoanalysis was the leading outpatient psychiatric therapy. Beginning in the late 1980s, its star began to fade with the rise of safer psychotropics, the outcomes of which are easier to quantify. It also takes less time to see results with drug therapy in the clinical setting, compared with the various forms of psychotherapies – some of which require three or more visits weekly.

“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”

Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.

And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.

Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.

Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”

In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”

Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.

The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.

He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”

Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”

Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Most psychiatrists are familiar with many of the basic tenets of psychoanalysis, but they probably aren’t relying on its therapeutic powers in practice as much as they are pharmacotherapy, according to an expert.

“There’s a great deal of discussion about whether psychoanalysis has an adequate evidence base. That’s a popular concept. It’s not so much about whether practitioners want to use it, but whether or not they can defend using it in their dialogs with insurance companies, government agencies, and other sources of support,” Robert Michels, MD, a Walsh McDermott University Professor of Medicine, and professor of psychiatry, at Cornell University, New York, said at the annual meeting of the American College of Psychiatrists. “My summary is that it has less adequate data supporting it [than pharmacologic interventions]. … There is, however, convincing evidence that all of these treatments, ranging from cognitive-behavioral therapy to [dialectical behavior therapy], to dynamic psychoanalysis, to mentalization-based treatment, do have an effect.”

Michels_Robert_NYC_web.jpg

For much of the 20th century, psychoanalysis was the leading outpatient psychiatric therapy. Beginning in the late 1980s, its star began to fade with the rise of safer psychotropics, the outcomes of which are easier to quantify. It also takes less time to see results with drug therapy in the clinical setting, compared with the various forms of psychotherapies – some of which require three or more visits weekly.

“The SSRI probably did more to change psychotherapy than any other evolutionary change in the theory of psychotherapy,” Dr. Michels said. “In the beginning, [pharmacologic treatments] were not terribly useful to the patients of psychoanalysis, because they were too toxic or too psychologically disturbing to use in people without major psychiatric problems. Now, [there is] intense competition from biologic treatments.”

Whereas the goal of pharmacotherapy is cure, the point of psychoanalysis is to derive meaning from neurosis, and ultimately, from life. A sea change in thought about how psychoanalysis should be conducted was well underway before the advent of fluoxetine, however. With the death in 1939 of Sigmund Freud, MD, the founder of psychoanalysis, a wave of theories began to wash over the field. Most of those theories do not see memories as the enemy, or detachment from the patient as appropriate, according to Dr. Michels.

And while the form might vary across the different approaches, the function is the same. “The goal is no longer to recover the lost memory of the childhood trauma. More important is the journey in attempting to discover it,” Dr. Michels said.

Freud avoided seeing his patients as having personality disorders, while the next generations of psychotherapists largely embraced and conceptualized diagnoses, going beyond symptoms and instead focusing on the person’s predisposition to symptom formation. Psychotherapy today sees pathology not as something to be cured but as a reaction to problems tied to everyday living. It assumes that a more effective reaction to those problems can be learned.

Rather than shun what were once considered obstacles – resistance, enactment, transference, countertransference, and working through interpretations – the psychotherapist uses those to establish a relationship with the patient; emotions stirred by the therapist become important markers of patterns that have persisted in the person’s life that prevent forming smooth relationships, and vice versa. “In the new model, the therapist is an actively engaged participant whose core skill is to stay fully involved and interconnected while also being able to step back and say, ‘What is happening here?’ ” Dr. Michels said. “Transference and countertransference are essential tools to the therapeutic process. Hopefully, we change the patient’s attitude to his own mental life and toward others around him. We have a much more open, broader, wider way of dealing with patients, and we are much more humble about what we know before the treatment starts.”

In an interview, Dr. Michels said this has been especially helpful in treating people with borderline personality disorder, for whom the neutral face of a therapist can often be a trigger. “You end up being a better player through collaboration. If you carry the argument to its extreme, we’d say it doesn’t make any difference if you discover the flaw.”

Also in the interview, Dr. Michels said that, while many therapists are aware that psychotherapy has evolved and that it is effective, it is still not commonly taught in medical schools beyond a basic level because of the “finite nature of the amount of time to learn what students are required to learn in order to be a skilled psychotherapist, regardless of whether they have the raw talent for it.” Outcomes of pharmacologic therapies are easier to measure, and that is another reason psychotherapy is “troublesome,” he said. Most psychotherapists prefer not having to justify its use to third-party payers.

The tension between the therapist and insurers should not automatically be a deterrent to expanding access to talk therapy according to the meeting’s program chair, Scott T. Aaronson, MD, director of clinical research at the Sheppard Pratt Health System, Baltimore. “I don’t think that psychoanalysis has ever been a great friend of insurance. I think we need to educate insurance companies on what psychotherapy means. Instead, we just sort of allow them to make rules. It’s been a one-way street that needs to change,” Dr. Aaronson said in an interview.

He and Dr. Michels said data collection on patient outcomes would help. Collecting the hospitalization rates, morbidity and mortality, and medical care costs of people who have received psychotherapy may be worthwhile and would be fairly straightforward to do, according to Dr. Aaronson. “I would worry [about factoring in] those who have been getting psychiatric care off the grid skewing statistics, but if your patient population is of a moderate-income group, very few of those people could afford private care.”

Even if clinicians do not include newer psychoanalytic techniques in practice, Dr. Aaronson said, they “should keep up to date on the trends, and be aware that for many patients, modalities such as mentalization have been exquisitely helpful.”

Neither Dr. Michels nor Dr. Aaronson had any relevant disclosures.

 

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.

“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.

ACA_ipad_web.jpg

In a premeeting session on the future of integrated care, Dr. Summergrad, the Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts University, Boston, pointed to two current trends in Washington that are affecting mental health care. The first is a clamor for repeal of the ACA, which includes pressure from employers who are unhappy with the mandate to provide health insurance to employees; the second is a desire on the part of some lawmakers to slow the growth of state Medicaid budgets by rolling back the federal program’s expansion under the ACA and replacing it with block grants. In opposition, the recent passage of the bipartisan and highly pro–mental health care 21st Century Cures Act calls for more block grants for services for the seriously mentally ill, including those who currently are incarcerated with serious mental illness and substance use disorders, as well as for increased training programs to expand the behavioral health workforce, among other measures.

“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”

Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.

In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.

He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.

As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”

In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”

Dr. Summergrad had no relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.

“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.

ACA_ipad_web.jpg

In a premeeting session on the future of integrated care, Dr. Summergrad, the Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts University, Boston, pointed to two current trends in Washington that are affecting mental health care. The first is a clamor for repeal of the ACA, which includes pressure from employers who are unhappy with the mandate to provide health insurance to employees; the second is a desire on the part of some lawmakers to slow the growth of state Medicaid budgets by rolling back the federal program’s expansion under the ACA and replacing it with block grants. In opposition, the recent passage of the bipartisan and highly pro–mental health care 21st Century Cures Act calls for more block grants for services for the seriously mentally ill, including those who currently are incarcerated with serious mental illness and substance use disorders, as well as for increased training programs to expand the behavioral health workforce, among other measures.

“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”

Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.

In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.

He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.

As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”

In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”

Dr. Summergrad had no relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

 

SCOTTSDALE, ARIZ. – Whether or not the Affordable Care Act (ACA) is repealed, replaced, reviled, or revered should not deter psychiatrists and primary care physicians from seeking to work together, according to a leading expert on integrating mental health care in medical practice.

“Community-based psychiatrists should be focused on finding ways to help create integrated models of care, both in health systems and in other settings, to provide mental health specialty support for primary care providers, regardless of whatever else is going on [in Washington],” Paul Summergrad, MD, said in an interview at the annual meeting of the American College of Psychiatrists.

ACA_ipad_web.jpg

In a premeeting session on the future of integrated care, Dr. Summergrad, the Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts University, Boston, pointed to two current trends in Washington that are affecting mental health care. The first is a clamor for repeal of the ACA, which includes pressure from employers who are unhappy with the mandate to provide health insurance to employees; the second is a desire on the part of some lawmakers to slow the growth of state Medicaid budgets by rolling back the federal program’s expansion under the ACA and replacing it with block grants. In opposition, the recent passage of the bipartisan and highly pro–mental health care 21st Century Cures Act calls for more block grants for services for the seriously mentally ill, including those who currently are incarcerated with serious mental illness and substance use disorders, as well as for increased training programs to expand the behavioral health workforce, among other measures.

“If Medicaid expansion is replaced with block grants, that would lead to less care in general for Medicaid recipients,” Dr. Summergrad said in the interview. “It depends on how the states would view their costs of care, and how they would view the medical psychiatric issues.”

Since Medicaid is the largest payer of mental and behavioral health services in the country with reimbursable models of collaborative care, cutting funding for those services would sting. “There’s evidence that addressing mental and behavioral health issues keeps medical costs low,” said Dr. Summergrad, a past president of the American Psychiatric Association.

In his talk, Dr. Summergrad pointed to the now decade-old IMPACT study (Improving Mood: Promoting Access to Collaborative Treatment) which showed that patients screened for depression when presenting with chronic medical issues had lower overall medical costs over time.

He also referred to a more recent study in a large Utah health system that showed overall cost savings, far-fewer emergency department admissions, and better patient outcomes across a wide range of medical issues, which were achieved when mental health services were integrated into routine care: in all, a $12 million investment resulted in $52 million in savings after 4 years (JAMA. 2016;316[8]:826-34). “Utah is not exactly a blue state, but it worked for them,” Dr. Summergrad said. The key was that physicians “embraced normalizing mental health care,” he said.

As for how any changes to the Medicare Access and CHIP Reauthorization Act, which is predicated largely on team-based care for higher reimbursements, Dr. Summergrad said cash-only psychiatrists should be thinking about how to collaborate with primary care providers. “I think the important message at this point is that, however this works, we’ll have to think about integrated care.”

In an interview, Lee H. Beecher, MD, agreed. In fact, Dr. Beecher said that, in his state of Minnesota, engaging with patients on a cash-only basis is the only way a psychiatrist can have a private practice and provide valuable, essential communication with primary care physicians. “Direct-pay physicians are uniquely able to actively facilitate communication,” said Dr. Beecher, president of the nonprofit Minnesota Physician-Patient Alliance. “Most of this is done by phone, directly, with the primary care clinician – rather than inputting and sending an electronic health record.”

Dr. Summergrad had no relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight