Randy Dotinga

LAS VEGAS – When she brings up dermatomyositis in the context of dermatology, Alisa Femia, MD, often hears from trainees and medical students who assume that this is a condition for rheumatologists to diagnose and treat. That’s not true: Dermatologists need to watch for this potentially fatal connective tissue disorder because they may see it first, she said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“A fifth are clinically amyopathic,” and they may not initially see a rheumatologist, said Dr. Femia, director of inpatient dermatology at the department of dermatology, New York University. “They have normal muscle enzymes and no muscle weakness. It really puts them in our care as dermatologists.”

The challenge is that patient presentations can be subtle, but the stakes may be high, she added. “If we catch them early and treat some of these patients aggressively, we can save their lives.”

During the presentation, Dr. Femia provided these pearls for diagnosing dermatomyositis:

• Don’t rely on tests like biopsies to absolutely tell you what’s going on. “Clinical examination is the most important test to establish the diagnosis,” she said. “If you’re suspecting dermatomyositis ... get the patient in a gown [for a full-body exam] and look for all the signs that might not be as prominent as they are in our textbooks.”
• Look for the “butterfly” rash on the midface that is unique because it spares the nasolabial folds. “It looks like someone took an eraser and wiped out those areas,” Dr. Femia said. “This is important to help us nail down the diagnosis.”
• Other telltale signs, she said, include erythema on the extensor surfaces of digits, severe itching in the scalp, and a rash on the eyelids.
• Be aware of pulmonary involvement, including interstitial lung disease. In some cases, patients and their physicians wrongly believe that patients with dermatomyositis have asthma or pneumonia. “Pulmonologists are not necessarily aware of lung disease associated with dermatomyositis,” she said.

It’s wise to refer patients with dermatomyositis for malignancy and lung disease screening even if they don’t show signs of muscular involvement. “There’s no significant difference in rates of malignancy or lung disease in classic versus amyopathic dermatomyositis.”

Keep the MDA5 form of dermatomyositis in mind, Dr. Femia said. Anti–melanoma differentiation–associated gene 5 dermatomyositis is linked to rapidly progressive interstitial lung disease, alopecia, arthritis and oral lacerations. “Initially, it can have features of lupus, and the patient can be on immunosuppressive therapy, which mitigates diagnostic findings.”

Dr. Femia disclosed serving as principal investigator for a clinical trial in cutaneous dermatomyositis therapy.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – When she brings up dermatomyositis in the context of dermatology, Alisa Femia, MD, often hears from trainees and medical students who assume that this is a condition for rheumatologists to diagnose and treat. That’s not true: Dermatologists need to watch for this potentially fatal connective tissue disorder because they may see it first, she said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“A fifth are clinically amyopathic,” and they may not initially see a rheumatologist, said Dr. Femia, director of inpatient dermatology at the department of dermatology, New York University. “They have normal muscle enzymes and no muscle weakness. It really puts them in our care as dermatologists.”

The challenge is that patient presentations can be subtle, but the stakes may be high, she added. “If we catch them early and treat some of these patients aggressively, we can save their lives.”

During the presentation, Dr. Femia provided these pearls for diagnosing dermatomyositis:

• Don’t rely on tests like biopsies to absolutely tell you what’s going on. “Clinical examination is the most important test to establish the diagnosis,” she said. “If you’re suspecting dermatomyositis ... get the patient in a gown [for a full-body exam] and look for all the signs that might not be as prominent as they are in our textbooks.”
• Look for the “butterfly” rash on the midface that is unique because it spares the nasolabial folds. “It looks like someone took an eraser and wiped out those areas,” Dr. Femia said. “This is important to help us nail down the diagnosis.”
• Other telltale signs, she said, include erythema on the extensor surfaces of digits, severe itching in the scalp, and a rash on the eyelids.
• Be aware of pulmonary involvement, including interstitial lung disease. In some cases, patients and their physicians wrongly believe that patients with dermatomyositis have asthma or pneumonia. “Pulmonologists are not necessarily aware of lung disease associated with dermatomyositis,” she said.

It’s wise to refer patients with dermatomyositis for malignancy and lung disease screening even if they don’t show signs of muscular involvement. “There’s no significant difference in rates of malignancy or lung disease in classic versus amyopathic dermatomyositis.”

Keep the MDA5 form of dermatomyositis in mind, Dr. Femia said. Anti–melanoma differentiation–associated gene 5 dermatomyositis is linked to rapidly progressive interstitial lung disease, alopecia, arthritis and oral lacerations. “Initially, it can have features of lupus, and the patient can be on immunosuppressive therapy, which mitigates diagnostic findings.”

Dr. Femia disclosed serving as principal investigator for a clinical trial in cutaneous dermatomyositis therapy.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – When she brings up dermatomyositis in the context of dermatology, Alisa Femia, MD, often hears from trainees and medical students who assume that this is a condition for rheumatologists to diagnose and treat. That’s not true: Dermatologists need to watch for this potentially fatal connective tissue disorder because they may see it first, she said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

“A fifth are clinically amyopathic,” and they may not initially see a rheumatologist, said Dr. Femia, director of inpatient dermatology at the department of dermatology, New York University. “They have normal muscle enzymes and no muscle weakness. It really puts them in our care as dermatologists.”

The challenge is that patient presentations can be subtle, but the stakes may be high, she added. “If we catch them early and treat some of these patients aggressively, we can save their lives.”

During the presentation, Dr. Femia provided these pearls for diagnosing dermatomyositis:

• Don’t rely on tests like biopsies to absolutely tell you what’s going on. “Clinical examination is the most important test to establish the diagnosis,” she said. “If you’re suspecting dermatomyositis ... get the patient in a gown [for a full-body exam] and look for all the signs that might not be as prominent as they are in our textbooks.”
• Look for the “butterfly” rash on the midface that is unique because it spares the nasolabial folds. “It looks like someone took an eraser and wiped out those areas,” Dr. Femia said. “This is important to help us nail down the diagnosis.”
• Other telltale signs, she said, include erythema on the extensor surfaces of digits, severe itching in the scalp, and a rash on the eyelids.
• Be aware of pulmonary involvement, including interstitial lung disease. In some cases, patients and their physicians wrongly believe that patients with dermatomyositis have asthma or pneumonia. “Pulmonologists are not necessarily aware of lung disease associated with dermatomyositis,” she said.

It’s wise to refer patients with dermatomyositis for malignancy and lung disease screening even if they don’t show signs of muscular involvement. “There’s no significant difference in rates of malignancy or lung disease in classic versus amyopathic dermatomyositis.”

Keep the MDA5 form of dermatomyositis in mind, Dr. Femia said. Anti–melanoma differentiation–associated gene 5 dermatomyositis is linked to rapidly progressive interstitial lung disease, alopecia, arthritis and oral lacerations. “Initially, it can have features of lupus, and the patient can be on immunosuppressive therapy, which mitigates diagnostic findings.”

Dr. Femia disclosed serving as principal investigator for a clinical trial in cutaneous dermatomyositis therapy.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Cases of cutaneous squamous cell carcinoma (cSCC) are on the rise and are associated with mortality rates similar to melanoma. But even as cSCC draws more attention, two popular staging systems still need refinement, a hematologist-oncologist told dermatologist colleagues.

Both staging systems can be helpful, however, Guilherme Rabinowits, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “The best thing to do is combine both,” he noted, referring to the staging system developed by the Brigham and Women’s Hospital (BWH) and staging systems released in the 7th and 8th editions of the American Joint Committee on Cancer Staging Manual (AJCC 7 and AJCC 8; the latter focuses on head and neck only).

Cutaneous SCC has become a “huge health care burden,” said Dr. Rabinowits of the Miami Cancer Institute/Baptist Health South Florida and Florida International University, Miami. He referred to Medicare data suggesting that cSCC has become as common as basal cell carcinoma (JAMA Dermatol. 2015 Oct;151[10]:1081-6).

While most patients with cSCC have a positive prognosis, he added, the 5-year survival rate among those with the most aggressive disease is only 25%.

As he pointed out, staging systems provide insight into prognosis and treatment, guide appropriate monitoring, and give a common language to clinicians around the world. “When I talk about stage 3, we all understand who we’re talking about,” he said.

Dr. Rabinowits said he formerly worked at BWH so he is especially comfortable with its staging system. It can be appropriate to use both the BWH and AJCC systems at once, he said, noting, however, that studies suggest that the BWH system is superior.

An analysis released in 2014, for example, found that most poor outcomes occurred in patients whose tumors had been rated at lower stages – suggesting less risk – in the AJCC 7 system (J Clin Oncol 2014 Feb 1;32[4]:327-4).

In contrast, the 5% of tumors that were rated at the highest stages in the BWH system – with the highest level of perceived risk – accounted for 70% of nodal metastases and 83% of disease-specific deaths. This group may deserve extra attention in terms of staging and adjuvant treatment in order to improve outcomes, he said.

A study published this year, which compared the BWH and AJCC 8 staging systems, found that they had the same negative predictive value (0.99), while the BWH system showed higher positive predictive value (0.30 vs. 0.17). “Use of BWH tumor classification may minimize the number of patients recommended for radiologic evaluation, close surveillance, and possible adjuvant therapy while still identifying most patients at risk for recurrence, metastasis, and death,” the authors wrote (JAMA Dermatol. 2019 Jul 1;155[7]: 819-25).

As for treatment of localized disease in high-risk patients, Dr. Rabinowits advised turning to a multidisciplinary team for guidance because there are limited prospective randomized data.

Dr. Rabinowits discloses scientific advisory board/consultant relationships (Merck, Regeneron, Sanofi, EMD Serono, Pfizer, and Castle) and shares in Regeneron and Syros Pharmaceuticals. He spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Cases of cutaneous squamous cell carcinoma (cSCC) are on the rise and are associated with mortality rates similar to melanoma. But even as cSCC draws more attention, two popular staging systems still need refinement, a hematologist-oncologist told dermatologist colleagues.

Both staging systems can be helpful, however, Guilherme Rabinowits, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “The best thing to do is combine both,” he noted, referring to the staging system developed by the Brigham and Women’s Hospital (BWH) and staging systems released in the 7th and 8th editions of the American Joint Committee on Cancer Staging Manual (AJCC 7 and AJCC 8; the latter focuses on head and neck only).

Cutaneous SCC has become a “huge health care burden,” said Dr. Rabinowits of the Miami Cancer Institute/Baptist Health South Florida and Florida International University, Miami. He referred to Medicare data suggesting that cSCC has become as common as basal cell carcinoma (JAMA Dermatol. 2015 Oct;151[10]:1081-6).

While most patients with cSCC have a positive prognosis, he added, the 5-year survival rate among those with the most aggressive disease is only 25%.

As he pointed out, staging systems provide insight into prognosis and treatment, guide appropriate monitoring, and give a common language to clinicians around the world. “When I talk about stage 3, we all understand who we’re talking about,” he said.

Dr. Rabinowits said he formerly worked at BWH so he is especially comfortable with its staging system. It can be appropriate to use both the BWH and AJCC systems at once, he said, noting, however, that studies suggest that the BWH system is superior.

An analysis released in 2014, for example, found that most poor outcomes occurred in patients whose tumors had been rated at lower stages – suggesting less risk – in the AJCC 7 system (J Clin Oncol 2014 Feb 1;32[4]:327-4).

In contrast, the 5% of tumors that were rated at the highest stages in the BWH system – with the highest level of perceived risk – accounted for 70% of nodal metastases and 83% of disease-specific deaths. This group may deserve extra attention in terms of staging and adjuvant treatment in order to improve outcomes, he said.

A study published this year, which compared the BWH and AJCC 8 staging systems, found that they had the same negative predictive value (0.99), while the BWH system showed higher positive predictive value (0.30 vs. 0.17). “Use of BWH tumor classification may minimize the number of patients recommended for radiologic evaluation, close surveillance, and possible adjuvant therapy while still identifying most patients at risk for recurrence, metastasis, and death,” the authors wrote (JAMA Dermatol. 2019 Jul 1;155[7]: 819-25).

As for treatment of localized disease in high-risk patients, Dr. Rabinowits advised turning to a multidisciplinary team for guidance because there are limited prospective randomized data.

Dr. Rabinowits discloses scientific advisory board/consultant relationships (Merck, Regeneron, Sanofi, EMD Serono, Pfizer, and Castle) and shares in Regeneron and Syros Pharmaceuticals. He spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Cases of cutaneous squamous cell carcinoma (cSCC) are on the rise and are associated with mortality rates similar to melanoma. But even as cSCC draws more attention, two popular staging systems still need refinement, a hematologist-oncologist told dermatologist colleagues.

Both staging systems can be helpful, however, Guilherme Rabinowits, MD, said at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar. “The best thing to do is combine both,” he noted, referring to the staging system developed by the Brigham and Women’s Hospital (BWH) and staging systems released in the 7th and 8th editions of the American Joint Committee on Cancer Staging Manual (AJCC 7 and AJCC 8; the latter focuses on head and neck only).

Cutaneous SCC has become a “huge health care burden,” said Dr. Rabinowits of the Miami Cancer Institute/Baptist Health South Florida and Florida International University, Miami. He referred to Medicare data suggesting that cSCC has become as common as basal cell carcinoma (JAMA Dermatol. 2015 Oct;151[10]:1081-6).

While most patients with cSCC have a positive prognosis, he added, the 5-year survival rate among those with the most aggressive disease is only 25%.

As he pointed out, staging systems provide insight into prognosis and treatment, guide appropriate monitoring, and give a common language to clinicians around the world. “When I talk about stage 3, we all understand who we’re talking about,” he said.

Dr. Rabinowits said he formerly worked at BWH so he is especially comfortable with its staging system. It can be appropriate to use both the BWH and AJCC systems at once, he said, noting, however, that studies suggest that the BWH system is superior.

An analysis released in 2014, for example, found that most poor outcomes occurred in patients whose tumors had been rated at lower stages – suggesting less risk – in the AJCC 7 system (J Clin Oncol 2014 Feb 1;32[4]:327-4).

In contrast, the 5% of tumors that were rated at the highest stages in the BWH system – with the highest level of perceived risk – accounted for 70% of nodal metastases and 83% of disease-specific deaths. This group may deserve extra attention in terms of staging and adjuvant treatment in order to improve outcomes, he said.

A study published this year, which compared the BWH and AJCC 8 staging systems, found that they had the same negative predictive value (0.99), while the BWH system showed higher positive predictive value (0.30 vs. 0.17). “Use of BWH tumor classification may minimize the number of patients recommended for radiologic evaluation, close surveillance, and possible adjuvant therapy while still identifying most patients at risk for recurrence, metastasis, and death,” the authors wrote (JAMA Dermatol. 2019 Jul 1;155[7]: 819-25).

As for treatment of localized disease in high-risk patients, Dr. Rabinowits advised turning to a multidisciplinary team for guidance because there are limited prospective randomized data.

Dr. Rabinowits discloses scientific advisory board/consultant relationships (Merck, Regeneron, Sanofi, EMD Serono, Pfizer, and Castle) and shares in Regeneron and Syros Pharmaceuticals. He spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Dermatologists in Oregon have launched a project that targets melanoma by promoting education and early detection, with the goal of dramatically reducing melanoma deaths in the state of 4.2 million people.

Research shows that “early detection works in melanoma. And awareness seems to be important for the public in detecting melanoma early,” said Sancy Leachman, MD, PhD, professor and chair of the department of dermatology at Oregon Health & Science University, Portland, said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Leachman, who is also the John D. Gray chair in melanoma research at OHSU, directs the “War on Melanoma” project, which was inspired by a project in the German state of Schleswig-Holstein that aimed to screen all residents aged over 21 years for melanoma. The project featured an education campaign and population-wide skin cancer screening, and mandated that certain patients – those at high risk and those who needed biopsies – would be referred to dermatologists (Br J Cancer. 2012 Feb 28;106[5]:970-4).

According to Dr. Leachman, the German project was initially a success, and was linked to a 50% decrease in melanoma mortality.

“In Oregon, we thought ‘that sounds very good, so we’re going to try that.’ ” But when it went national, the German project failed, she said, providing lessons for dermatologists in Oregon. “We’re going to try to improve upon the first [German] experiment by making ours controlled with a defined baseline. If it works, the plan is to extend it to select states nationwide.”

The War on Melanoma project was launched earlier this year. According to the university, the program is featuring or will feature the following elements:

• A media campaign called “Start Seeing Melanoma” that’s devoted to educating the public about the early detection of melanoma.
• The release of an iPhone app called MoleMapper that allows users to monitor moles over time.
• Education of medical professionals and partnerships with state-licensed skin care professionals such as massage therapists, cosmetologists, and tattoo artists.

In an interview at the meeting, Dr. Leachman said the project is expected to cost $1 million to $1.5 million over the first 18 months. At that time, she said, researchers will survey residents of Oregon and two control states – Washington and Utah– to see if their knowledge of melanoma has improved, compared with baseline survey results.

In 5 years, researchers plan to begin analyzing melanoma mortality in Oregon and the other states. “We hope to see a decline,” and to link it to increased awareness of melanoma, she said.

Dr. Leachman reported no relevant disclosures. She spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Dermatologists in Oregon have launched a project that targets melanoma by promoting education and early detection, with the goal of dramatically reducing melanoma deaths in the state of 4.2 million people.

Research shows that “early detection works in melanoma. And awareness seems to be important for the public in detecting melanoma early,” said Sancy Leachman, MD, PhD, professor and chair of the department of dermatology at Oregon Health & Science University, Portland, said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Leachman, who is also the John D. Gray chair in melanoma research at OHSU, directs the “War on Melanoma” project, which was inspired by a project in the German state of Schleswig-Holstein that aimed to screen all residents aged over 21 years for melanoma. The project featured an education campaign and population-wide skin cancer screening, and mandated that certain patients – those at high risk and those who needed biopsies – would be referred to dermatologists (Br J Cancer. 2012 Feb 28;106[5]:970-4).

According to Dr. Leachman, the German project was initially a success, and was linked to a 50% decrease in melanoma mortality.

“In Oregon, we thought ‘that sounds very good, so we’re going to try that.’ ” But when it went national, the German project failed, she said, providing lessons for dermatologists in Oregon. “We’re going to try to improve upon the first [German] experiment by making ours controlled with a defined baseline. If it works, the plan is to extend it to select states nationwide.”

The War on Melanoma project was launched earlier this year. According to the university, the program is featuring or will feature the following elements:

• A media campaign called “Start Seeing Melanoma” that’s devoted to educating the public about the early detection of melanoma.
• The release of an iPhone app called MoleMapper that allows users to monitor moles over time.
• Education of medical professionals and partnerships with state-licensed skin care professionals such as massage therapists, cosmetologists, and tattoo artists.

In an interview at the meeting, Dr. Leachman said the project is expected to cost $1 million to $1.5 million over the first 18 months. At that time, she said, researchers will survey residents of Oregon and two control states – Washington and Utah– to see if their knowledge of melanoma has improved, compared with baseline survey results.

In 5 years, researchers plan to begin analyzing melanoma mortality in Oregon and the other states. “We hope to see a decline,” and to link it to increased awareness of melanoma, she said.

Dr. Leachman reported no relevant disclosures. She spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

LAS VEGAS – Dermatologists in Oregon have launched a project that targets melanoma by promoting education and early detection, with the goal of dramatically reducing melanoma deaths in the state of 4.2 million people.

Research shows that “early detection works in melanoma. And awareness seems to be important for the public in detecting melanoma early,” said Sancy Leachman, MD, PhD, professor and chair of the department of dermatology at Oregon Health & Science University, Portland, said at the Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.

Dr. Leachman, who is also the John D. Gray chair in melanoma research at OHSU, directs the “War on Melanoma” project, which was inspired by a project in the German state of Schleswig-Holstein that aimed to screen all residents aged over 21 years for melanoma. The project featured an education campaign and population-wide skin cancer screening, and mandated that certain patients – those at high risk and those who needed biopsies – would be referred to dermatologists (Br J Cancer. 2012 Feb 28;106[5]:970-4).

According to Dr. Leachman, the German project was initially a success, and was linked to a 50% decrease in melanoma mortality.

“In Oregon, we thought ‘that sounds very good, so we’re going to try that.’ ” But when it went national, the German project failed, she said, providing lessons for dermatologists in Oregon. “We’re going to try to improve upon the first [German] experiment by making ours controlled with a defined baseline. If it works, the plan is to extend it to select states nationwide.”

The War on Melanoma project was launched earlier this year. According to the university, the program is featuring or will feature the following elements:

• A media campaign called “Start Seeing Melanoma” that’s devoted to educating the public about the early detection of melanoma.
• The release of an iPhone app called MoleMapper that allows users to monitor moles over time.
• Education of medical professionals and partnerships with state-licensed skin care professionals such as massage therapists, cosmetologists, and tattoo artists.

In an interview at the meeting, Dr. Leachman said the project is expected to cost $1 million to $1.5 million over the first 18 months. At that time, she said, researchers will survey residents of Oregon and two control states – Washington and Utah– to see if their knowledge of melanoma has improved, compared with baseline survey results.

In 5 years, researchers plan to begin analyzing melanoma mortality in Oregon and the other states. “We hope to see a decline,” and to link it to increased awareness of melanoma, she said.

Dr. Leachman reported no relevant disclosures. She spoke during a forum on cutaneous malignancies at the meeting.

SDEF and this news organization are owned by the same parent company.

Researchers have developed models that successfully predict persistent postoperative pain (PPP) after total knee arthroplasty (TKA) two-thirds of the time. Major risk factors include pre-operative pain, sensory testing results, anxiety and anticipated pain.

“The results of this study provide some basis for the identification of patients at risk of PPP after TKA and highlight several modifiable factors that may be targeted by clinicians in an attempt to reduce the risk of developing PPP,” write the authors of the study, which appeared in the British Journal of Anaesthesia.

The authors, led by David Rice, PhD, of Auckland University of Technology, note that moderate to severe levels of PPP affect an estimated 10%-34% of patients at least 3 months after TKA surgery. “PPP adversely affects quality of life, is the most important predictor of patient dissatisfaction after TKA, and is a common reason for undergoing revision surgery.”

The researchers, who launched the study to gain insight into the risk factors that can predict PPP, recruited 300 New Zealand volunteers (average age = 69, 48% female, 92% white, average body mass index [BMI] = 31 kg/m²) to be surveyed before and after TKA surgery. They monitored pain and tracked a long list of possible risk factors including psychological traits (such as anxiety, pain catastrophizing and depression), physical traits (such as gender, BMI), and surgical traits (such as total surgery time).

At 6 months, 21% of 291 patients reported moderate to severe pain, and the percentage fell to 16% in 288 patients at 12 months.

The researchers developed two models that successfully predicted moderate-to-severe PPP.

The 6-month model relied on higher levels of preoperative pain intensity, temporal summation (a statistic that’s based on quantitative sensory testing), trait anxiety (a measure of individual anxiety level), and expected pain. It correctly predicted moderate to severe PPP 66% of the time (area under the curve [AUC] = 0.70, sensitivity = 0.72, specificity = 0.64).

The 12-month model relied on higher levels of all the risk factors except for temporal summation and correctly predicted moderate-to-severe PPP 66% of the time (AUC = 0.66, sensitivity = 0.61, specificity = 0.67).

The researchers noted that other research has linked trait anxiety and expected pain to PPP. In regard to anxiety, “cognitive behavioral interventions in the perioperative period aimed at reducing the threat value of surgery and of postoperative pain, improving patients’ coping strategies, and enhancing self-efficacy might help to reduce the risk of PPP after TKA,” the researchers write. “Furthermore, there is some evidence that anxiolytic medications can diminish perioperative anxiety and reduce APOP [acute postoperative pain] although its effects on PPP are unclear.”

Moving forward, the authors write, “strategies to minimize intraoperative nerve injury, reduce preoperative pain intensity, and address preoperative psychological factors such as expected pain and anxiety may lead to improved outcomes after TKA and should be explored.”

The Australia New Zealand College of Anesthetists and Auckland University of Technology funded the study. The study authors report no relevant disclosures.

SOURCE: Rice D et al. Br J Anaesth 2018;804-12. doi: https://doi.org/10.1016/j.bja.2018.05.070.

Researchers have developed models that successfully predict persistent postoperative pain (PPP) after total knee arthroplasty (TKA) two-thirds of the time. Major risk factors include pre-operative pain, sensory testing results, anxiety and anticipated pain.

“The results of this study provide some basis for the identification of patients at risk of PPP after TKA and highlight several modifiable factors that may be targeted by clinicians in an attempt to reduce the risk of developing PPP,” write the authors of the study, which appeared in the British Journal of Anaesthesia.

The authors, led by David Rice, PhD, of Auckland University of Technology, note that moderate to severe levels of PPP affect an estimated 10%-34% of patients at least 3 months after TKA surgery. “PPP adversely affects quality of life, is the most important predictor of patient dissatisfaction after TKA, and is a common reason for undergoing revision surgery.”

The researchers, who launched the study to gain insight into the risk factors that can predict PPP, recruited 300 New Zealand volunteers (average age = 69, 48% female, 92% white, average body mass index [BMI] = 31 kg/m²) to be surveyed before and after TKA surgery. They monitored pain and tracked a long list of possible risk factors including psychological traits (such as anxiety, pain catastrophizing and depression), physical traits (such as gender, BMI), and surgical traits (such as total surgery time).

At 6 months, 21% of 291 patients reported moderate to severe pain, and the percentage fell to 16% in 288 patients at 12 months.

The researchers developed two models that successfully predicted moderate-to-severe PPP.

The 6-month model relied on higher levels of preoperative pain intensity, temporal summation (a statistic that’s based on quantitative sensory testing), trait anxiety (a measure of individual anxiety level), and expected pain. It correctly predicted moderate to severe PPP 66% of the time (area under the curve [AUC] = 0.70, sensitivity = 0.72, specificity = 0.64).

The 12-month model relied on higher levels of all the risk factors except for temporal summation and correctly predicted moderate-to-severe PPP 66% of the time (AUC = 0.66, sensitivity = 0.61, specificity = 0.67).

The researchers noted that other research has linked trait anxiety and expected pain to PPP. In regard to anxiety, “cognitive behavioral interventions in the perioperative period aimed at reducing the threat value of surgery and of postoperative pain, improving patients’ coping strategies, and enhancing self-efficacy might help to reduce the risk of PPP after TKA,” the researchers write. “Furthermore, there is some evidence that anxiolytic medications can diminish perioperative anxiety and reduce APOP [acute postoperative pain] although its effects on PPP are unclear.”

Moving forward, the authors write, “strategies to minimize intraoperative nerve injury, reduce preoperative pain intensity, and address preoperative psychological factors such as expected pain and anxiety may lead to improved outcomes after TKA and should be explored.”

The Australia New Zealand College of Anesthetists and Auckland University of Technology funded the study. The study authors report no relevant disclosures.

SOURCE: Rice D et al. Br J Anaesth 2018;804-12. doi: https://doi.org/10.1016/j.bja.2018.05.070.

Researchers have developed models that successfully predict persistent postoperative pain (PPP) after total knee arthroplasty (TKA) two-thirds of the time. Major risk factors include pre-operative pain, sensory testing results, anxiety and anticipated pain.

“The results of this study provide some basis for the identification of patients at risk of PPP after TKA and highlight several modifiable factors that may be targeted by clinicians in an attempt to reduce the risk of developing PPP,” write the authors of the study, which appeared in the British Journal of Anaesthesia.

The authors, led by David Rice, PhD, of Auckland University of Technology, note that moderate to severe levels of PPP affect an estimated 10%-34% of patients at least 3 months after TKA surgery. “PPP adversely affects quality of life, is the most important predictor of patient dissatisfaction after TKA, and is a common reason for undergoing revision surgery.”

The researchers, who launched the study to gain insight into the risk factors that can predict PPP, recruited 300 New Zealand volunteers (average age = 69, 48% female, 92% white, average body mass index [BMI] = 31 kg/m²) to be surveyed before and after TKA surgery. They monitored pain and tracked a long list of possible risk factors including psychological traits (such as anxiety, pain catastrophizing and depression), physical traits (such as gender, BMI), and surgical traits (such as total surgery time).

At 6 months, 21% of 291 patients reported moderate to severe pain, and the percentage fell to 16% in 288 patients at 12 months.

The researchers developed two models that successfully predicted moderate-to-severe PPP.

The 6-month model relied on higher levels of preoperative pain intensity, temporal summation (a statistic that’s based on quantitative sensory testing), trait anxiety (a measure of individual anxiety level), and expected pain. It correctly predicted moderate to severe PPP 66% of the time (area under the curve [AUC] = 0.70, sensitivity = 0.72, specificity = 0.64).

The 12-month model relied on higher levels of all the risk factors except for temporal summation and correctly predicted moderate-to-severe PPP 66% of the time (AUC = 0.66, sensitivity = 0.61, specificity = 0.67).

The researchers noted that other research has linked trait anxiety and expected pain to PPP. In regard to anxiety, “cognitive behavioral interventions in the perioperative period aimed at reducing the threat value of surgery and of postoperative pain, improving patients’ coping strategies, and enhancing self-efficacy might help to reduce the risk of PPP after TKA,” the researchers write. “Furthermore, there is some evidence that anxiolytic medications can diminish perioperative anxiety and reduce APOP [acute postoperative pain] although its effects on PPP are unclear.”

Moving forward, the authors write, “strategies to minimize intraoperative nerve injury, reduce preoperative pain intensity, and address preoperative psychological factors such as expected pain and anxiety may lead to improved outcomes after TKA and should be explored.”

The Australia New Zealand College of Anesthetists and Auckland University of Technology funded the study. The study authors report no relevant disclosures.

SOURCE: Rice D et al. Br J Anaesth 2018;804-12. doi: https://doi.org/10.1016/j.bja.2018.05.070.

SAN DIEGO – Not long before his presentation at Psych Congress 2019, psychiatrist Rakesh Jain, MD, MPH, chatted with a fellow attendee, a nurse practitioner from Tyler, Tex. As Dr. Jain recalled later, his fellow Texan told him that “it’s not unusual to see patients on three benzodiazepines.”

The nurse practitioner “talks to them about how they need to do things differently, and they forget,” Dr. Jain said. “He’s very worried about them.”

Dr. Jain is familiar with the feeling. Like many mental health professionals, he worries about the role of benzodiazepines, which seem to be both widely used and misused. Figuring out their proper place in psychiatry “may require us to raise our game,” said Dr. Jain, of Texas Tech University in Midland.

What to do? Dr. Jain and a colleague offered the same answer – tread carefully, but do not eliminate them as an option – in two separate sessions at the annual Psych Congress.

As Dr. Jain noted, benzodiazepines are popular, and for good reason. “There are many patients, perhaps hundreds of thousands, who are using benzodiazepines chronically, and they’re doing it right. There’s not a CVS in America where benzodiazepines aren’t well stocked. They’re very inexpensive, and the most costly benzodiazepine is still cheaper than Motrin.”

On the other hand, he said, the medications are linked to addiction and physical dependence. “Thirty percent of those who die of opioid overdoses may not have died if they didn’t have benzodiazepines [in their systems].”

Be very cautious about prescribing as needed

“It’s rarely indicated to prescribe benzodiazepine [as needed] when you’re treating people with anxiety,” he said. “The main reason is patients don’t know when they need it. They take their pills either when they’re so anxious that they’ve already been freaking out for a long time, or they take it when they’re first starting to feel at least a bit anxious. That leads to taking it to prevent being anxious.”

Allow an as-needed approach in certain situations

It can be appropriate to prescribe benzodiazepines for specific short-term anxiety-provoking situations, such as speaking in public, Dr. Stein said.

However, he said, advise patients to try the medication beforehand so they understand its effects. “I’ve had one occasion where I thought we had a dose worked out well. Somebody had to do a work presentation, and he took the medicine and got up in front of the group. He wasn’t anxious at all. But he couldn’t remember a single thing.”
 

Don’t use them as patients start SSRIs

Patients can get anxious as they start SSRIs, especially for panic disorders, Dr. Stein said. So it might seem reasonable, as some psychiatrists believe, to add benzodiazepines on a short-term basis.

But Dr. Stein said he is not a fan of this approach. As he noted, benzodiazepines are hard to stop. He prefers to help patients understand possible side effects of SSRIs instead, and he emphasized the importance of being available to help patients get through them.

Dr. Jain and Dr. Stein each reported multiple relationships with industry.

SAN DIEGO – Not long before his presentation at Psych Congress 2019, psychiatrist Rakesh Jain, MD, MPH, chatted with a fellow attendee, a nurse practitioner from Tyler, Tex. As Dr. Jain recalled later, his fellow Texan told him that “it’s not unusual to see patients on three benzodiazepines.”

The nurse practitioner “talks to them about how they need to do things differently, and they forget,” Dr. Jain said. “He’s very worried about them.”

Dr. Jain is familiar with the feeling. Like many mental health professionals, he worries about the role of benzodiazepines, which seem to be both widely used and misused. Figuring out their proper place in psychiatry “may require us to raise our game,” said Dr. Jain, of Texas Tech University in Midland.

What to do? Dr. Jain and a colleague offered the same answer – tread carefully, but do not eliminate them as an option – in two separate sessions at the annual Psych Congress.

As Dr. Jain noted, benzodiazepines are popular, and for good reason. “There are many patients, perhaps hundreds of thousands, who are using benzodiazepines chronically, and they’re doing it right. There’s not a CVS in America where benzodiazepines aren’t well stocked. They’re very inexpensive, and the most costly benzodiazepine is still cheaper than Motrin.”

On the other hand, he said, the medications are linked to addiction and physical dependence. “Thirty percent of those who die of opioid overdoses may not have died if they didn’t have benzodiazepines [in their systems].”

Be very cautious about prescribing as needed

“It’s rarely indicated to prescribe benzodiazepine [as needed] when you’re treating people with anxiety,” he said. “The main reason is patients don’t know when they need it. They take their pills either when they’re so anxious that they’ve already been freaking out for a long time, or they take it when they’re first starting to feel at least a bit anxious. That leads to taking it to prevent being anxious.”

Allow an as-needed approach in certain situations

It can be appropriate to prescribe benzodiazepines for specific short-term anxiety-provoking situations, such as speaking in public, Dr. Stein said.

However, he said, advise patients to try the medication beforehand so they understand its effects. “I’ve had one occasion where I thought we had a dose worked out well. Somebody had to do a work presentation, and he took the medicine and got up in front of the group. He wasn’t anxious at all. But he couldn’t remember a single thing.”
 

Don’t use them as patients start SSRIs

Patients can get anxious as they start SSRIs, especially for panic disorders, Dr. Stein said. So it might seem reasonable, as some psychiatrists believe, to add benzodiazepines on a short-term basis.

But Dr. Stein said he is not a fan of this approach. As he noted, benzodiazepines are hard to stop. He prefers to help patients understand possible side effects of SSRIs instead, and he emphasized the importance of being available to help patients get through them.

Dr. Jain and Dr. Stein each reported multiple relationships with industry.

SAN DIEGO – Not long before his presentation at Psych Congress 2019, psychiatrist Rakesh Jain, MD, MPH, chatted with a fellow attendee, a nurse practitioner from Tyler, Tex. As Dr. Jain recalled later, his fellow Texan told him that “it’s not unusual to see patients on three benzodiazepines.”

The nurse practitioner “talks to them about how they need to do things differently, and they forget,” Dr. Jain said. “He’s very worried about them.”

Dr. Jain is familiar with the feeling. Like many mental health professionals, he worries about the role of benzodiazepines, which seem to be both widely used and misused. Figuring out their proper place in psychiatry “may require us to raise our game,” said Dr. Jain, of Texas Tech University in Midland.

What to do? Dr. Jain and a colleague offered the same answer – tread carefully, but do not eliminate them as an option – in two separate sessions at the annual Psych Congress.

As Dr. Jain noted, benzodiazepines are popular, and for good reason. “There are many patients, perhaps hundreds of thousands, who are using benzodiazepines chronically, and they’re doing it right. There’s not a CVS in America where benzodiazepines aren’t well stocked. They’re very inexpensive, and the most costly benzodiazepine is still cheaper than Motrin.”

On the other hand, he said, the medications are linked to addiction and physical dependence. “Thirty percent of those who die of opioid overdoses may not have died if they didn’t have benzodiazepines [in their systems].”

Be very cautious about prescribing as needed

“It’s rarely indicated to prescribe benzodiazepine [as needed] when you’re treating people with anxiety,” he said. “The main reason is patients don’t know when they need it. They take their pills either when they’re so anxious that they’ve already been freaking out for a long time, or they take it when they’re first starting to feel at least a bit anxious. That leads to taking it to prevent being anxious.”

Allow an as-needed approach in certain situations

It can be appropriate to prescribe benzodiazepines for specific short-term anxiety-provoking situations, such as speaking in public, Dr. Stein said.

However, he said, advise patients to try the medication beforehand so they understand its effects. “I’ve had one occasion where I thought we had a dose worked out well. Somebody had to do a work presentation, and he took the medicine and got up in front of the group. He wasn’t anxious at all. But he couldn’t remember a single thing.”
 

Don’t use them as patients start SSRIs

Patients can get anxious as they start SSRIs, especially for panic disorders, Dr. Stein said. So it might seem reasonable, as some psychiatrists believe, to add benzodiazepines on a short-term basis.

But Dr. Stein said he is not a fan of this approach. As he noted, benzodiazepines are hard to stop. He prefers to help patients understand possible side effects of SSRIs instead, and he emphasized the importance of being available to help patients get through them.

Dr. Jain and Dr. Stein each reported multiple relationships with industry.

In tattoo removal, the impact of laser treatments in single office visits is limited because of the laser’s effects on the skin. Now, a new study suggests that a device that uses sound waves to “clear” skin cells can allow more laser passes in a single tattoo removal treatment session.

“As a result,” the authors of the study wrote, “a lower total number of office visits will likely be required for complete tattoo removal leading to improved convenience and efficiency as well as increased satisfaction for both patients and clinicians.” The study, led by cosmetic surgeon Michael S. Kaminer, MD, of SkinCare Physicians in Chestnut Hill, Mass., appeared in Lasers in Surgery and Medicine.

In the study, he and his coauthors pointed out that tattoos are most frequently removed with short-pulse high-fluence lasers, such as a 1064-nm Nd:YAG Q‐switched (QS) laser. However, “the QS laser has a limited ability to affect the tattoo ink pigment particles in each treatment session due to shielding of the pigment particles caused by both the agglomeration of the pigment particles and laser‐induced epidermal and dermal vacuoles known as ‘whitening.’ ” Therefore, “use of the QS laser often requires 10 or more single‐pass office sessions to achieve acceptable fading results.”

The study evaluated whether the use of a rapid acoustic pulse (RAP) device could reduce the whitening effect by clearing vacuoles and make it possible to increase the number of potential laser passes. In the single-center, prospective trial, they treated 32 black-ink tattoos in 21 patients, dividing the tattoos into zones and treating them differently: One zone received at least three consecutive laser passes alternating with a minute of treatment with the RAP device, one received single-pass laser treatment, and one received no treatment.

Reviewers assessed the tattoos for fading at 12 weeks. Average percent fading was higher in the laser/RAP group, compared with the laser-only group (44% and 25%, respectively, P less than .01). The percentages of tattoos with more than 50% fading (38% vs. 9%, P less than .01) and more than 75% fading (22% vs. 3%, P less than .05) were also higher in the laser/RAP group, compared with the laser-only group.

Courtesy Dr. Michael S. Kaminer

SOURCE: Kaminer MS et al. Lasers Surg Med. 2019 Sep 19. doi: 10.1002/lsm.23163.

In tattoo removal, the impact of laser treatments in single office visits is limited because of the laser’s effects on the skin. Now, a new study suggests that a device that uses sound waves to “clear” skin cells can allow more laser passes in a single tattoo removal treatment session.

“As a result,” the authors of the study wrote, “a lower total number of office visits will likely be required for complete tattoo removal leading to improved convenience and efficiency as well as increased satisfaction for both patients and clinicians.” The study, led by cosmetic surgeon Michael S. Kaminer, MD, of SkinCare Physicians in Chestnut Hill, Mass., appeared in Lasers in Surgery and Medicine.

In the study, he and his coauthors pointed out that tattoos are most frequently removed with short-pulse high-fluence lasers, such as a 1064-nm Nd:YAG Q‐switched (QS) laser. However, “the QS laser has a limited ability to affect the tattoo ink pigment particles in each treatment session due to shielding of the pigment particles caused by both the agglomeration of the pigment particles and laser‐induced epidermal and dermal vacuoles known as ‘whitening.’ ” Therefore, “use of the QS laser often requires 10 or more single‐pass office sessions to achieve acceptable fading results.”

The study evaluated whether the use of a rapid acoustic pulse (RAP) device could reduce the whitening effect by clearing vacuoles and make it possible to increase the number of potential laser passes. In the single-center, prospective trial, they treated 32 black-ink tattoos in 21 patients, dividing the tattoos into zones and treating them differently: One zone received at least three consecutive laser passes alternating with a minute of treatment with the RAP device, one received single-pass laser treatment, and one received no treatment.

Reviewers assessed the tattoos for fading at 12 weeks. Average percent fading was higher in the laser/RAP group, compared with the laser-only group (44% and 25%, respectively, P less than .01). The percentages of tattoos with more than 50% fading (38% vs. 9%, P less than .01) and more than 75% fading (22% vs. 3%, P less than .05) were also higher in the laser/RAP group, compared with the laser-only group.

Courtesy Dr. Michael S. Kaminer

SOURCE: Kaminer MS et al. Lasers Surg Med. 2019 Sep 19. doi: 10.1002/lsm.23163.

In tattoo removal, the impact of laser treatments in single office visits is limited because of the laser’s effects on the skin. Now, a new study suggests that a device that uses sound waves to “clear” skin cells can allow more laser passes in a single tattoo removal treatment session.

“As a result,” the authors of the study wrote, “a lower total number of office visits will likely be required for complete tattoo removal leading to improved convenience and efficiency as well as increased satisfaction for both patients and clinicians.” The study, led by cosmetic surgeon Michael S. Kaminer, MD, of SkinCare Physicians in Chestnut Hill, Mass., appeared in Lasers in Surgery and Medicine.

In the study, he and his coauthors pointed out that tattoos are most frequently removed with short-pulse high-fluence lasers, such as a 1064-nm Nd:YAG Q‐switched (QS) laser. However, “the QS laser has a limited ability to affect the tattoo ink pigment particles in each treatment session due to shielding of the pigment particles caused by both the agglomeration of the pigment particles and laser‐induced epidermal and dermal vacuoles known as ‘whitening.’ ” Therefore, “use of the QS laser often requires 10 or more single‐pass office sessions to achieve acceptable fading results.”

The study evaluated whether the use of a rapid acoustic pulse (RAP) device could reduce the whitening effect by clearing vacuoles and make it possible to increase the number of potential laser passes. In the single-center, prospective trial, they treated 32 black-ink tattoos in 21 patients, dividing the tattoos into zones and treating them differently: One zone received at least three consecutive laser passes alternating with a minute of treatment with the RAP device, one received single-pass laser treatment, and one received no treatment.

Reviewers assessed the tattoos for fading at 12 weeks. Average percent fading was higher in the laser/RAP group, compared with the laser-only group (44% and 25%, respectively, P less than .01). The percentages of tattoos with more than 50% fading (38% vs. 9%, P less than .01) and more than 75% fading (22% vs. 3%, P less than .05) were also higher in the laser/RAP group, compared with the laser-only group.

Courtesy Dr. Michael S. Kaminer

SOURCE: Kaminer MS et al. Lasers Surg Med. 2019 Sep 19. doi: 10.1002/lsm.23163.

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Research suggests that as many as 23% of patients with substance use disorder (SUD) also have ADHD, adding an extra layer of complexity to a difficult-to-treat condition. What to do?

“Treating the ADHD can be useful in reducing the severity of symptoms without worsening the substance use disorder. It shouldn’t be avoided,” said psychiatrist Larissa J. Mooney, MD, of the University of California, Los Angeles, and the Veterans Affairs Greater Los Angeles Healthcare System, in a presentation at the annual Psych Congress.

When ADHD is on board, “it’s a more complicated and challenging clinical course,” Dr. Mooney said. The duo of disorders is linked to higher rates of polysubstance abuse and other psychiatric conditions, such as anxiety, bipolar disorder, posttraumatic stress, and antisocial/borderline conditions (Eur Addict Res. 2018;24[1]:43-51).

“These individuals typically have more difficulty with [drug] abstinence, more health consequences, and reduced quality of life, and social and professional consequences,” she said. “Some studies have suggested that they may not respond to lower doses of medication for attention-deficit/hyperactivity disorder and may require doses in the higher range.”

Research has hinted that several drugs that might prove helpful in these patients by improving both conditions, Dr. Mooney said. These include up to 180 mg/day of methylphenidate (Ritalin), 60- and 80-mg doses of mixed amphetamine salts/extended release, atomoxetine (Strattera), and bupropion.

In regard to bupropion, she said, “I find it to be a good choice in my substance use disorder patients for their depression and concentration problems. I have a greater number of individuals at 450 milligrams per day and the XL formulation.”

Early research has suggested that guanfacine XR (Intuniv), which is used to treat children with ADHD, also might be helpful in adults, including those with SUD. “We need more research to show if this is helpful,” she said. “It’s a reasonable choice in terms of weighing pros and cons, because it’s not [a controlled substance].”

Still, some of those medications are stimulants, Dr. Mooney said, and their use in patients with SUD is controversial. There are concerns about misuse and diversion.

“We want to have some flexibility,” she said, but it’s important to think about risks and priorities. In certain cases, ADHD may be a secondary concern.

“Some patients have a severe substance use disorder that keeps landing them in the emergency room or causing them to be hospitalized,” she said. “I’m more worried about that than the impairment function from ADHD.”

If you do consider stimulants, she said, longer-acting formulations can be less risky because there’s less potential for diversion. “Also, think about their treatment plan: Is their functioning improving? Are they or showing up for appointments? These are factors that will say: ‘Oh, I’m on the right path with this medication.’ ”

Behavioral treatment also can be helpful in these patients, she said, although “some may not be willing or motivated to put in the time that it takes to do the behavioral work.”

Dr. Mooney disclosed an advisory board relationship with Alkermes and grant/research support from the National Institute on Drug Abuse.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Even if a P value hints at statistical significance by dipping under .05, it might not tell you anything worthwhile. Effect sizes are hugely important – as long as accompanying P values measure up. And pharmaceutical companies often keep revealing numbers under wraps unless you know what – and whom – to ask.

Those lessons come courtesy of Leslie Citrome, MD, MPH, who spoke to colleagues about study numbers at Psych Congress 2019.

Dr. Citrome, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, offered several tips about interpreting medical statistics as you make clinical decisions.

Don’t get hung up on the P value.

The P value helps you understand how likely it is that a difference in a study is statistically significant. In medical research, P values under .05 are considered especially desirable. They suggest that an outcome – drug A performed better than drug B, for example – didn’t happen purely by chance.

Here’s the hitch: The P value might not matter at all. “Clinicians often assume that if the P value is less than.05, the result must be important. But even a P value of less than .05 is meaningless outside of the context of how big the treatment effect is,” Dr. Citrome said. “If a clinical trial result shows us a small effect size, then who cares?”

Understand what effect sizes tell you.

Effect size measurements evaluate clinical impact and include number needed to treat (NNT) and number needed to harm (NNH). NNT refers to the number of patients needed to treat with an intervention in order to get a positive effect in one additional patient; NNH is the reverse and examines negative effects that can range from the minor (mild dry mouth) to the devastating (death).

What’s a good size for an NNT? “I respect any NNT versus placebo of less than 10,” Dr. Citrome said. “It’s something I’ll probably consider in day-to-day practice.” Double-digit and triple-digit NNTs “are usually irrelevant unless we’re dealing with very specific outcomes that have long-term consequences.”

As for the opposite side of the picture – NNH – values higher than 10 are ideal.

He cautioned that NNT and NNH, like P values, cannot stand alone. In fact, they work together. In order to have value, NNT or NNH must be statistically significant, and P values provide this crucial insight.

Consider Dr. Citrome’s blood pressure.

As Dr. Citrome noted, research suggests that, among patients with diastolic BP from 90 to 109 mm Hg, 1 additional person will avoid death, stroke, or heart attack for every 141 people who take an antihypertensive medication, compared to those who do not, over a 5-year period. That’s a lot of people taking medication for a long time, with potential side effects, for a fairly small effect size. However, the outcomes are dire, so it is still worth it. 

Then there’s Dr. Citrome himself, who has had diastolic BP in the range of 115 to 129 mm Hg. The NNT is 3. For every 3 people who take an antihypertensive vs. not over a 5-year period, 1 additional person will avoid a potentially catastrophic cardiovascular event.

“Guess who’s pretty adherent to taking his antihypertensive medication?” he asked. “I am.”

Ask for effect sizes if you don’t see them.

It’s not unusual for pharmaceutical representatives to avoid providing information about medication effect sizes. “The sales representatives as well as speakers at [Food and Drug Administration]–regulated promotional speaking events can only speak to basically what’s on the label. NNT and NNH are not currently found on product labels. But they are very relevant, and we need to know this information.”

What to do? “There is a workaround here,” he said. “Ask the sales rep to talk to a medical science liaison, who is free to come to your office and talk about all the data that they have.”

Dr. Citrome reported multiple disclosures, including various relationships with pharmaceutical companies.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – Physician suicide is “a public health crisis because of the sheer volume of people who are dying,” and many medical authorities are contributing to stigma through “invasive” questionnaires, a prevention advocate said at the annual Psych Congress.

“Physicians fear sharing their mental health struggles with the state medical health board,” said Pamela Wible, MD, a family physician who practices in Eugene, Ore., at the meeting. They “pretend, deny, and lie,” she said, and sometimes they seek care and medication hours away in order to avoid detection.

One solution, she said, is to highlight state medical boards that do it right and state medical boards that do it wrong, including the “very worst,” which is that of Alaska.

Dr. Wible, who speaks of suffering from suicidal feelings herself as physician in 2004, is a leading advocate for suicide prevention in the medical profession.

She told colleagues at the Psych Congress that anesthesiologists face the highest risk of suicide, followed by surgeons, ob.gyns., and psychiatrists.

“They end their lives not because they want to die but because they want to stop the pain and they can’t find any other way,” she said. “They have a great work ethic until the end: They’re smiling, doing complex surgeries, and cracking jokes to the surgical team, then they shoot themselves in the closet.”

Colleagues are often shocked, she said: “ ‘Wait a minute. He was just joking with me yesterday. What do you mean he hung himself in his office?’ ‘She just had a newborn baby and she was so happy!’ If you see the smile, you don’t see the pain.”

In 2018, she wrote a Washington Post commentary titled “What I’ve learned from my tally of 757 doctor suicides” that was based on her registry of physician suicides. In the United States, she wrote, 1 million patients lose a physician to suicide each year. Factors contributing to suicides include patient deaths, malpractice suits, “academic distress,” and overwork. “Doctors who need help don’t seek it because they fear mental health care won’t remain confidential,” she wrote. “So they drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans out of fear that they will lose state licensure, hospital privileges, and health plan participation.”

Dr. Wible oversaw a 2019 research project that analyzed state medical board applications. The goal was to grade the state boards by how intrusively their application questions grill applicants about their mental health history. “Physicians fear sharing their mental health struggles with the state medical health board and with each other,” she said. Some lie, and others – “the really honest physicians” – are so dedicated to telling the truth that “they’ll withhold getting care because they want to correctly check the ‘no’ box.”

Seven states – Alabama, Alaska, Delaware, Florida, Mississippi, Rhode Island, and Washington –received “F” grades for “highly invasive mental health questions unlinked to current impairment that contain confusing, punitive, or adversarial language.”

Roke~commonswiki

Alaska, Dr. Wible said, asks multiple 25 yes-or-no questions about mental health. One question lists 14 conditions, almost all related to mental health – including depression, “any organic mental disorder,” and “any condition requiring chronic medical or behavioral treatment” – and asks, “Have you ever been diagnosed with, treated for, or do you currently have” any of them. This is “the most invasive mental health question we found on any application,” Dr. Wible wrote on her website.

States also hurt applicants by asking peers of applicants about their mental health, she said. “I’m not against getting peer references, but can we stop getting into everyone’s business with their psych history? What we really want to know is: ‘Are you are safe with patients today?’ ”

Dr. Wible also criticizes state medical boards for asking about mental health impairment over the last 5 years: They don’t get higher than a “C.”

The 13 states with “A” grades either don’t ask about mental health or simply ask about general impairment: Connecticut, Hawaii, Indiana, Kentucky, New Jersey, Maine, Maryland, Massachusetts, Michigan, Nevada, New York, Pennsylvania, and Wyoming.

Massachusetts, for example, asks, “Do you have a medical or physical condition that currently impairs your ability to practice medicine?”

“That is a question anyone can understand,” Dr. Wible said. “I think that’s good wording.”

Going forward, she said, “we’ve got to remove these mental health questions. If we could do this, our profession would be so much better, and we’d lose so many fewer people.”

And, she added, “what we really need to do is share our stories. It’s therapeutic for you and your colleagues, it creates collegial trust and bonding, and it destigmatizes physician mental health.”

Dr. Wible reported no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.

SAN DIEGO – The Food and Drug Administration has not approved a drug to treat agitation in dementia, and the absence of medication candidates is only part of the picture. As a geriatric psychiatrist explained to colleagues, the FDA has not taken the step of recognizing that the condition exists. But there are still options to treat this dangerous disorder – although none is ideal.

Research into efficacy of potential treatments for agitation is limited, variable, and “have high placebo effects,” said Marc E. Agronin, MD, of the MIND Institute and Miami Jewish Health, at the annual Psych Congress. “There is no one single magic bullet, especially since there are so many manifestations of agitation, and there are side effects of medication. This is a tough area to focus on.”

What can clinicians do? Dr. Agronin recommended starting with the steps in the DICE algorithm.

• Describe: Learn about the aspects of agitation by talking to caregivers and understanding the circumstances when symptoms develop.
• Investigate: Identify contributing factors, such as those related to illness, medication, and the environment.
• Create: Come up with a team strategy to address the contributing factors. Address the most urgent risks first, such as danger to self or others, which can require quick action – such as medication adjustment, an ED visit, or psychiatric hospitalization. Delirium is especially dangerous since it can lead to injury and subacute cognitive decline. And keep in mind, Dr. Agorin said, that it may be risky to do nothing or undertreat.
• Evaluate: Track the results of the strategy while realizing that there’s “not always a quick fix.” Research suggests that therapeutic approaches such as music, aromatherapy, exercise, group activities, hand massage, and thermal baths can be helpful, Dr. Agronin said.

As for medications, he advised starting with lower doses, perhaps 50%, because older people are less tolerant of medication. And beware of oversedation, dizziness, and lowered blood pressure, which can lead to falls. A hip fracture can “spiral down to someone’s demise very quickly,” he said.

Here’s a closer look at Dr. Agronin’s comments regarding specific medications.

• Antipsychotics: “Every antipsychotic has been used for agitation,” he said, “and they probably have the best efficacy,” compared with other drugs. But the risk of side effects is moderate to high, and atypical antipsychotics have a black-box warning about their use in dementia-related psychosis in elderly patients. Also, discontinuation of antipsychotics can trigger worsening symptoms in some patients. There has been tremendous controversy in recent years over the use of antipsychotics in older patients, but other drugs might be less effective than antipsychotics while still having similar side effect profiles, he said. And clinicians might be too cautious about doses even when they do use these drugs.
• Benzodiazepines: They can work quickly but come with a risk of sedation. Trazodone is an “excellent” alternative to reduce agitation in the short-term, he said.
• Antidepressants: These drugs can address underlying depression. Study results have been mixed.
• Mood stabilizers: Study results are mixed. “Unfortunately, in many situations [clinicians] get scared away from antipsychotics and use mood stabilizers, but there is less data for them in terms of efficacy, and there are a lot of side effects that have to be monitored,” he said.

Dr. Agronin is the author of “How We Age” (Da Capo Lifelong Books, 2012) and “The End of Old Age” (Da Capo Lifelong Books, 2018). He has no relevant disclosures.