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March 2018: Click for Credit
Here are 4 articles in the March issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Prenatal Maternal Anxiety Linked to Hyperactivity in Offspring as Teenagers
To take the posttest, go to: http://bit.ly/2BLXsRs
Expires November 15, 2018
2. The Better Mammogram: Experts Explore Sensitivity of New Modalities
To take the posttest, go to: http://bit.ly/2nQaJii
Expires November 14, 2018
3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors
To take the posttest, go to: http://bit.ly/2E3tcmJ
Expires November 14, 2018
4. Salivary Biomarker for Huntington Disease Identified
To take the posttest, go to: http://bit.ly/2BGQpJP
Expires November 13, 2018
Here are 4 articles in the March issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Prenatal Maternal Anxiety Linked to Hyperactivity in Offspring as Teenagers
To take the posttest, go to: http://bit.ly/2BLXsRs
Expires November 15, 2018
2. The Better Mammogram: Experts Explore Sensitivity of New Modalities
To take the posttest, go to: http://bit.ly/2nQaJii
Expires November 14, 2018
3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors
To take the posttest, go to: http://bit.ly/2E3tcmJ
Expires November 14, 2018
4. Salivary Biomarker for Huntington Disease Identified
To take the posttest, go to: http://bit.ly/2BGQpJP
Expires November 13, 2018
Here are 4 articles in the March issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Prenatal Maternal Anxiety Linked to Hyperactivity in Offspring as Teenagers
To take the posttest, go to: http://bit.ly/2BLXsRs
Expires November 15, 2018
2. The Better Mammogram: Experts Explore Sensitivity of New Modalities
To take the posttest, go to: http://bit.ly/2nQaJii
Expires November 14, 2018
3. Large Database Analysis Suggests Safety of Bariatric Surgery in Seniors
To take the posttest, go to: http://bit.ly/2E3tcmJ
Expires November 14, 2018
4. Salivary Biomarker for Huntington Disease Identified
To take the posttest, go to: http://bit.ly/2BGQpJP
Expires November 13, 2018
Deeply entrenched gender bias in academic medicine is treatable
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
Patricia Devine et al. in a recent study published in the Journal of Experimental Social Psychology tested the effect of one 2.5-hour workshop that sought to positively influence the mental habit of gender bias, which exists in our academic world (and elsewhere) in both men and women.
Bevra H. Hahn, MD, is Distinguished Professor of Medicine (emeritus) at the University of California, Los Angeles.
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
TAMPA, FLA. – Gender bias that disadvantages women from rising in academic medicine might require specific habit-changing strategies rather than efforts that draw on goodwill alone, according to new follow-up data from a randomized trial discussed and reevaluated at the annual meeting of the American College of Psychiatrists.
One premise of this trial, supported by other research, is that entrenched gender stereotypes drive both male and female behavior and must be addressed directly for change, said Molly Carnes, MD, professor of psychiatry at the University of Wisconsin, Madison.
The initial results of the trial, which randomized academic departments at the University of Wisconsin to participate in habit-changing workshops or to serve as controls, were published almost 3 years ago (Acad Med. 2015 Feb;90[2]:221-30). It is the most recent follow-up (Devine et al. J Exp Soc Psychol. 2017 Nov;73:211-5) that corroborates that long-term changes are possible with intervention.
The published findings showed that when 1,137 faculty members from 46 departments in the experimental arm were compared with 1,153 faculty members from 46 departments in the control arm, there were significant improvements in the experimental arm in surveyed attitudes reflecting personal bias awareness (P = .001) and willingness to support gender equity (P = .013).
These changes in attitude translated into concrete changes in new female faculty hires in the most recent analysis. From 32% in a 2-year period before the workshops, the new female hires climbed to 46% in the 2-year period after the workshops – a relative increase of 44% in the departments participating in the experimental arm. In the control departments, female new faculty hires remained at 32% in both time periods.
“Basically, there are 20 new women faculty members at the University of Wisconsin because of this study,” Dr. Carnes said.
. The result was a fundamental change in culture within departments randomized to the experimental arm, according to data generated by a variety of study analyses.
“When we looked at questions about department climate, we found that both male and female faculty members in the experimental groups were significantly more likely to say they fit in their department, they felt respected for their research and scholarship by their colleagues, and they felt comfortable raising personal and family issues even if they conflicted with departmental activities,” Dr. Carnes said.
This general attitude change is important, because Dr. Carnes emphasized that women share the cultural biases that can result in reduced female career opportunities in clinical and academic medicine. In addition, women generally are aware that stereotypical positive “agentic” adjectives for men, such as decisive, competitive, and ambitious, often are viewed negatively and generate backlash when applied to women. They therefore act on this awareness.
“Stereotype-based bias is a habit that can be broken, but it requires more than good intentions,” said Dr. Carnes, who emphasized that “gender-based assumptions and stereotypes are deeply embedded in the patterns of thinking of both men and women.”
As one example, Dr. Carnes cited her work evaluating female resident behavior when leading in-hospital code resuscitations. There are data to show that there is no difference in the effectiveness of male and female resident code leaders, but women typically feel that the assertive, aggressive behavior required for code leadership is “counternormative.” After the code, some women feel compelled to apologize to team members for being demanding or assertive, a step that Dr. Carnes attributed at least in part to fear of backlash from stepping out of gender-expected behavior.
The fix is not necessarily suppression of gender-related attributes. Dr. Carnes cited evidence that the stereotypical positive communal adjectives for women, such as nurturing, supportive, and sympathetic, might explain why studies suggest that women are more likely than men to be transformational leaders who inspire team members to contribute beyond their own self-interest in achieving goals.
Ultimately, the fix is replacement of stereotypes that impair men as well as women from defusing biases that “lead to subtle unintentional advantages in academic career advancement for Jack not afforded to Jill,” Dr. Carnes said. Based on the low numbers of female leaders in academic medicine decades after medical schools began enrolling women in substantial numbers, she concluded that meaningful change in gender bias is not likely to occur without implementation of specific proactive strategies aimed at challenging current perceptions. Her published study confirms that such strategies can help.
Dr. Carnes reported no conflicts of interest.
REPORTING FROM THE COLLEGE 2018
Goldwater Rule should be modified, debate audience at The College agrees
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
TAMPA, FLA. – Most psychiatrists believe that the so-called “Goldwater Rule” should be amended if an informal poll conducted at the annual meeting of the American College of Psychiatrists reflects dominant opinion.
The poll was conducted at the end of a debate between Nada L. Stotland, MD, who argued for no change, and Steven S. Sharfstein, MD, who argued that the ethical standard may have made sense when created in 1973 “but is now outmoded.”
The American Psychiatric Association introduced what is widely known as the Goldwater Rule into the APA code of ethics following an infamous survey of psychiatrists published in 1964. In that survey, the respondents overwhelmingly expressed the opinion that Barry Goldwater, the Arizona senator and 1964 candidate for president of the United States, was unfit to serve, an outcome that many considered an embarrassment for the APA.
As written, the ethical standard introduced by the APA proscribes psychiatrists from pronouncing a diagnosis of mental illness in public figures who they have not examined. The standard was later amended to disallow any professional opinion on mental health in public figures, not just a diagnosis.
This standard, always controversial, has been increasingly challenged as a result of concerns expressed frequently in public forums about the mental health of the current president. The moderator of the debate, John M. Oldman, MD, chair for personality disorders in the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston, commented that President Donald Trump “may be the death of the Goldwater rule.”
Even though not all agreed that a psychiatric diagnosis requires a face-to-face evaluation, the debate centered on the justification for banning psychiatrists from offering any opinion about the mental health of a public figure. Can an opinion be justified on the basis of First Amendment guarantees of free speech if the speaker identifies him or herself as a psychiatrist?
Dr. Sharfstein, who is president emeritus, Sheppard Pratt Health System, Baltimore, concluded that this prohibition is too far reaching. By his interpretation, psychiatrists who call a public figure “a jerk” are potentially violating the Goldwater Rule. Although he conceded that he is sensitive to the etiquette of demeaning public figures when speaking in the capacity of a psychiatrist, he said that banning the expression of opinions “is unenforceable.”
Dr. Stotland, professor of psychiatry at Rush Medical College, Chicago, disagreed. She argued that comments on mental health status expressed by a psychiatrist carry different weight than other citizens. Like boxers, whose fists are considered legal weapons in some states, a psychiatrist “should give up the right to express casual opinions” about psychopathology in a public figure, she said.
As professional opinions will almost certainly differ between psychiatrists, Dr. Stotland also suggested that an inevitable variety of opinions expressed by different psychiatrists about a public figure is not likely to contribute usefully to the general discourse. “Dissension in our public remarks undermines the credibility of our profession,” she said.
Although Dr. Sharfstein questioned whether psychiatrists have an ethical or moral obligation to “make the profession look good,” he conceded that there is room for civility when making pronouncements about the mental health status of public figures. Nevertheless, he reiterated that a ban on the expression of opinion is untenable. Citing the words of another critic of the Goldwater Rule, he argued, “Every psychiatrist has a first amendment right to make an idiot of themselves.”
For her part, Dr. Stotland suggested it is reasonable to ask whether psychiatrists questioning the mental health of a political leader are offering “a diagnosis or an accusation.” She cautioned about “using psychiatry as a weapon” in political debate.
Distinguishing professional from political opinions when speaking about mental health is a “slippery slope,” agreed Dr. Sharfstein, but he expressed concern about the ethics of not speaking out when a psychiatrist is convinced that a leader is psychologically unstable.
In the informal vote following the debate, the audience was provided with four options: retain the Goldwater Rule, abandon the Goldwater Rule, modify the Goldwater Rule, or abstain from voting. A large majority of the audience voted for a modification, overwhelming all three of the other options. Yet, it could not be determined from the show of hands what specific changes the audience members had in mind.
Dr. Oldham, Dr. Sharfstein, and Dr. Stotland reported no conflicts of interest relevant to this topic.
AT THE COLLEGE 2018
Consultation is key defense against sexual boundary violations in psychiatry
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
TAMPA, FLA. – Although there are very limited data on the risks, frequency, or consequences of sexual boundary violations in psychiatry, a personal experience evaluating, treating, or consulting in 300 such cases suggests that violators often consider their behavior to be justified, at least initially, according to an overview presented at the annual meeting of the American College of Psychiatrists.
“The capacity for individuals to rationalize their actions is just extraordinary,” said Glen O. Gabbard, MD, of the department of psychiatry and behavioral sciences at Baylor College of Medicine, Houston. He explained that many, if not all, violators are familiar with the reasons that sex between therapists and patients is unethical, but they typically consider their specific case exceptional.
These psychiatrists “will look you straight in the eye when telling you they are in love. They are convinced that there is nothing they can do. There is often no reasoning with these individuals,” Dr. Gabbard said.
Like many of these sexual boundary violations, those driven by the lovesickness syndrome typically reach a sexual relationship slowly. This is the reason that building a consultation into routine practice can be a critical defense against inappropriate treatment relationships, according to Dr. Gabbard. He suggested that it is important for psychiatrists to be open with the consultant therapist about all aspects of treatment, particularly ones that may be unflattering, and selecting a consultant who will not hesitate to challenge questionable behavior.
Self-monitoring questions represent another defense. Therapists will be able to recognize red flags when answering self-posed questions about whether there are aspects of any treatment or patient relationship they would not be willing to share with a colleague, whether there is any part of treatment that they would be unwilling to put in the patient’s chart, whether all treatment activities fit into a therapeutic plan, and whether everything they are doing meets community standards.
One obstacle to understanding the issue of sexual boundary violations is that it has remained “shrouded in secrecy despite a long history of transgressions,” according to Dr. Gabbard. There is very little reliable information about how often it occurs, the most common characteristics of therapists at risk for committing sexual boundary violations, or whether the incidence has been rising, falling, or has remained relatively constant.
In his anecdotal series of cases, Dr. Gabbard noted that 85% of the violators have been male therapists crossing sexual boundaries with female patients, but he cautioned that this might be a skewed sample.
“Males who have sex with female therapists often feel triumphant,” Dr. Gabbard said. This may explain why complaints by male patients against female therapists are relatively uncommon. However, citing several cases, Dr. Gabbard said that the general outrage is typically greater when a female therapist is the perpetrator.
Regardless of the circumstances, sexual relations with a patient are always a breach of fiduciary duty, Dr. Gabbard said. Nothing justifies this behavior. For example, a subsequent marriage between a therapist and his or her patient is not a mitigating proof of a justifiable romance. Rather, not least because of the unequal power dynamics between a therapist and his or her patient, Dr. Gabbard warned that such marriages have a strong potential for adverse long-term consequences for the well being of the patient.
Defenses are needed against sexual boundary violations, because sexual attraction involves complex dynamics with insidious effects on thought processes that are not always clear to the individuals involved. The line between flattery, charm, admiration, and friendliness can blur progressively into a sexualized relationship, particularly if physical contact, such as hugs, provides an opportunity to express sexual attraction.
Clinicians at risk of blurring these lines in the course of their efforts to help a patient should consider a key principle of lifeguarding, Dr. Gabbard said. He explained that lifeguards are taught to make sure they are safe before engaging in a rescue. This reason, according to Dr. Gabbard, is, “Drowning victims can take you with them.”
Dr. Gabbard reported no relevant conflicts of interest.
REPORTING FROM THE COLLEGE 2018
Tryptophan depletion may explain high rate of eating disorders in women
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
TAMPA, FLA. – The far higher rate of eating disorders in women than men appears to be explained at least in part by a greater acute depletion of tryptophan, which is essential for the formation of serotonin, a key mediator of risk, according to a research review presented at the annual meeting of the American College of Psychiatrists.
“The specific vulnerability of women to eating disorders relates to the fact that women’s brains are much more sensitive to dietary intake of tryptophan than are men’s brains,” explained Allan S. Kaplan, MD, senior scientist at the Center for Addiction and Mental Health at the University of Toronto.
“Women are more likely than men to be dieting,” said Dr. Kaplan, walking through the evidence. “Low-calorie diets tend to be high in protein and low in cholesterol and fat. Such diets lead to tryptophan depletion and decreased serotonin synthesis in the brain. Because of lower levels of central serotonin, women are more vulnerable to mood and eating disorders than men.”
Not all women who diet may be vulnerable to this sequence of events. Genetics are likely to be a factor, according to Dr. Kaplan, who said, “Genes load the gun; the environment pulls the trigger.”
However, women do appear to be more susceptible for a number of reasons. For one, the mean rate of serotonin synthesis is 52% higher in normal males than normal females, giving them a greater buffer when dietary intake of tryptophan is low. For another, there is evidence that intake of nutrients most rich in tryptophan, particularly proteins, is typically lower in women than men.
The ratio of females to males for both anorexia nervosa and bulimia nervosa is about 10:1. Although the female-to-male ratio of binge eating is lower at 2:1, women dominate these psychiatric diagnoses. Several environmental factors associated with eating disorders are more closely associated with women than men, including a history of sexual or physical abuse and female preoccupation with body image, but acute tryptophan depletion may be an important factor participating in the translation of risk to an active disease, according to Dr. Kaplan.
Acute tryptophan deficiency may also explain why treatment of eating disorders with SSRIs has been disappointing. With low levels of tryptophan leading to serotonin depletion, “there is no substrate” for drugs administered to increase serotonin-mediated signaling, Dr. Kaplan explained.
Ensuring adequate dietary intake of tryptophan, which is “found mainly in high-protein animal foods,” may be important, even though Dr. Kaplan warned that achieving optimal levels of serotonin “can be challenging from food alone.” Nevertheless, behavioral therapies are commonly effective for eating disorders, presumably at least partially as a result of their ability to normalize diet.
Overall, the tryptophan hypothesis has provided a major shift in the understanding of eating disorders, according to Dr. Kaplan. Further studies are needed, but he said that the key message is that, “For women’s brains, you are what you eat.”
Dr. Kaplan reported no conflicts of interest relevant to this topic.
This story was updated on 2/25/2018.
EXPERT ANALYSIS FROM THE COLLEGE 2018
For women with alcohol SUD, try gender-specific treatment
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
TAMPA – The distinct features of substance use disorders (SUDs) in women argue for gender-specific treatment, according to a comprehensive update presented at the annual meeting of the American College of Psychiatrists.
“There is a shorter time between landmarks of SUD progression, and these landmarks are reached at lower doses of alcohol consumed less frequently,” reported Shelly F. Greenfield, MD, chief academic officer at McLean Hospital in Boston.
“For each ounce of alcohol consumed, the blood alcohol concentration is higher with a greater potential for adverse physical consequences,” Dr. Greenfield said. These physiologic differences may account for the more rapid progression of SUD severity in women, a phenomenon that Dr. Greenfield referred to as “telescoping.” She said the same type of telescoping, defined as “an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment” (Psychiatr Clin North Am. 2011 Jun 28;33[2]:339-55), also has been seen among women for opioids and stimulants (Drug Alcohol Depend. 2004 Jun 11;74[3]:265-72). These greater risks are reflected in a higher SUD-associated mortality in females, compared with SUD-associated mortality in males.
Relative rates of alcohol SUD among women have been climbing steadily for more than 30 years. In the 1980s, for example, a population survey estimated the male-to-female prevalence ratio of alcohol SUD as 5:1. Citing subsequent surveys, Dr. Greenfield traced a rapid narrowing of the gender gap. In one of the most recent surveys, the rate had fallen below 2:1. Rates of heaving drinking and binge drinking are now about 1.4:1 in individuals aged 18-25 years.
“Each time we look at this gap, it has narrowed further,” Dr. Greenfield said. In another survey she cited, illicit drug use among adolescents between ages 12 and 17 years was higher in boys, but alcohol use in males and females was essentially the same.
Several facts suggest that treatment specific to women will improve outcomes. For one, For another, women are more likely to have co-occurring psychiatric disorders. In one study, anxiety (60.7% vs. 35.8%) and mood disorders (53.5% vs. 28.1%) were nearly twice as common in women with SUDs than in their male counterparts. This is relevant to interventions tailored for females because of evidence showing that treatment for SUDs and co-occurring psychiatric disorders should be integrated rather than addressed independently, according to Dr. Greenfield.
Importantly, “there is evidence of improved treatment outcome in women-focused programs,” Dr. Greenfield said. She suggested that successful programs for alcohol SUD in women not only address gender-specific features but that success can be enhanced further with adjunctive services that address the barriers to treatment, such as child care challenges and stigma – which Dr. Greenfield said is greater in women than in men.
A study called the Women’s Recovery Group (WRG), funded by the National Institute on Drug Abuse and led by Dr. Greenfield, is among those that have reinforced the value of female-specific therapy for SUD (Drug Alcohol Depend. 2014 Sep 1;142:245-53). A manual developed from the study and published in a book she wrote called “Treating Women With Substance Use Disorders: The Women’s Recovery Group Manual” (New York: The Guilford Press, 2016), outlines the principles. Dr. Greenfield said the structured 12-session group therapy for relapse prevention has been effective and well received by women. Some of those women have commented on the reinforcing value of shared experiences.
Up until now, women with alcohol SUD have been commonly treated alongside men, but Dr. Greenfield contended that treatment outcomes with alcohol SUD or other forms of SUDs “can be enhanced by programs that provide services specific to women’s needs.” She believes strategies aimed at addressing the more common histories of sexual or physical trauma and psychiatric comorbidities along with gender-related barriers to treatment have the potential to increase treatment success.
In addition to writing “Treating Women With Substance Use Disorders,” Dr. Greenfield is a coeditor of “Women and Addiction: A Comprehensive Handbook” (New York: Guilford, 2009). She reported no conflicts of interest.
REPORTING FROM THE COLLEGE 2018
Is anxiety normal or pathological? Age of onset is key
NEW YORK – Anxiety has become a common descriptor for fears, worries, or concerns, but the diagnosis of anxiety as a pathological affective disorder in children requires attention to the age of onset and the types of triggers, according to a presentation at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“Normal anxiety involves predictable triggers like a test in school,” explained John T. Walkup, MD, director of the division of child and adolescent psychiatry at Children’s Hospital, Northwestern University, Chicago. In the absence of the trigger, the symptoms abate or resolve.
“Age of onset is an important clue,” said Dr. Walkup, reporting that signs of pathological anxiety typically develop between the ages of 6 and 12 years. In comparison, symptoms of ADHD and autism spectrum disorder typically begin at younger ages, while the onset of affective disorders, such as depression or bipolar disease, typically occur at older ages.
Persistent symptoms may not be limited to children with pathological anxiety. Dr. Walkup said many children contend with “bad schools, troubled homes, and interpersonal violence,” creating “a huge population that meets the criteria for anxiety disorder,” even when the solution is eliminating the triggers rather than seeking an underlying psychiatric disorder.
Conversely, families of children with clear manifestations of anxiety might resist this diagnostic label.
“Parents tell me that their kids are not anxious; they are stressed out,” Dr. Walkup recounted. “These families see the external world as the problem for a kid who actually has internal problems regulating their anxious state.”
Rather than quibbling about terminology, patients should be educated about the very real threat posed by persistent and untreated symptoms, Dr. Walkup suggested. Pathological anxiety, regardless of the term used, is not a phase.
“Some of these kids do recover from childhood onset anxiety, but more often, the condition tracks to adolescence or adulthood,” Dr. Walkup said. . He contended that many adults with personality disorders are experiencing the consequences of distorted thinking and problematic emotional responses that began with childhood anxiety.
“Children with anxiety need to learn to cope. If you medicate them to control the anxiety, it does not necessarily mean that they will learn how to live anxiety free,” Dr. Walkup said, reiterating that pathological anxiety often persists indefinitely even after effective therapy diminishes the symptom burden. To improve a supportive family environment for an anxious child, he encouraged educating parents about the condition.
“One of the many books published on childhood anxiety may be all they need,” said Dr. Walkup, listing several examples, such as “You and Your Anxious Child” (New York: Avery, 2013) coauthored by Anne Marie Albano, PhD, a professor of child psychiatry at Columbia University in New York.
As anxiety is such a ubiquitous human experience, many parents trivialize the pathological variety, Dr. Walkup said. Educating patients about the immediate and long-term risks of pathological anxiety is important. The associated symptoms are not a phase, as some parents are likely to contend. He believes that early diagnosis and effective management can change the trajectory of a lifelong threat.
Dr. Walkup reported no potential conflicts of interest.
NEW YORK – Anxiety has become a common descriptor for fears, worries, or concerns, but the diagnosis of anxiety as a pathological affective disorder in children requires attention to the age of onset and the types of triggers, according to a presentation at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“Normal anxiety involves predictable triggers like a test in school,” explained John T. Walkup, MD, director of the division of child and adolescent psychiatry at Children’s Hospital, Northwestern University, Chicago. In the absence of the trigger, the symptoms abate or resolve.
“Age of onset is an important clue,” said Dr. Walkup, reporting that signs of pathological anxiety typically develop between the ages of 6 and 12 years. In comparison, symptoms of ADHD and autism spectrum disorder typically begin at younger ages, while the onset of affective disorders, such as depression or bipolar disease, typically occur at older ages.
Persistent symptoms may not be limited to children with pathological anxiety. Dr. Walkup said many children contend with “bad schools, troubled homes, and interpersonal violence,” creating “a huge population that meets the criteria for anxiety disorder,” even when the solution is eliminating the triggers rather than seeking an underlying psychiatric disorder.
Conversely, families of children with clear manifestations of anxiety might resist this diagnostic label.
“Parents tell me that their kids are not anxious; they are stressed out,” Dr. Walkup recounted. “These families see the external world as the problem for a kid who actually has internal problems regulating their anxious state.”
Rather than quibbling about terminology, patients should be educated about the very real threat posed by persistent and untreated symptoms, Dr. Walkup suggested. Pathological anxiety, regardless of the term used, is not a phase.
“Some of these kids do recover from childhood onset anxiety, but more often, the condition tracks to adolescence or adulthood,” Dr. Walkup said. . He contended that many adults with personality disorders are experiencing the consequences of distorted thinking and problematic emotional responses that began with childhood anxiety.
“Children with anxiety need to learn to cope. If you medicate them to control the anxiety, it does not necessarily mean that they will learn how to live anxiety free,” Dr. Walkup said, reiterating that pathological anxiety often persists indefinitely even after effective therapy diminishes the symptom burden. To improve a supportive family environment for an anxious child, he encouraged educating parents about the condition.
“One of the many books published on childhood anxiety may be all they need,” said Dr. Walkup, listing several examples, such as “You and Your Anxious Child” (New York: Avery, 2013) coauthored by Anne Marie Albano, PhD, a professor of child psychiatry at Columbia University in New York.
As anxiety is such a ubiquitous human experience, many parents trivialize the pathological variety, Dr. Walkup said. Educating patients about the immediate and long-term risks of pathological anxiety is important. The associated symptoms are not a phase, as some parents are likely to contend. He believes that early diagnosis and effective management can change the trajectory of a lifelong threat.
Dr. Walkup reported no potential conflicts of interest.
NEW YORK – Anxiety has become a common descriptor for fears, worries, or concerns, but the diagnosis of anxiety as a pathological affective disorder in children requires attention to the age of onset and the types of triggers, according to a presentation at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
“Normal anxiety involves predictable triggers like a test in school,” explained John T. Walkup, MD, director of the division of child and adolescent psychiatry at Children’s Hospital, Northwestern University, Chicago. In the absence of the trigger, the symptoms abate or resolve.
“Age of onset is an important clue,” said Dr. Walkup, reporting that signs of pathological anxiety typically develop between the ages of 6 and 12 years. In comparison, symptoms of ADHD and autism spectrum disorder typically begin at younger ages, while the onset of affective disorders, such as depression or bipolar disease, typically occur at older ages.
Persistent symptoms may not be limited to children with pathological anxiety. Dr. Walkup said many children contend with “bad schools, troubled homes, and interpersonal violence,” creating “a huge population that meets the criteria for anxiety disorder,” even when the solution is eliminating the triggers rather than seeking an underlying psychiatric disorder.
Conversely, families of children with clear manifestations of anxiety might resist this diagnostic label.
“Parents tell me that their kids are not anxious; they are stressed out,” Dr. Walkup recounted. “These families see the external world as the problem for a kid who actually has internal problems regulating their anxious state.”
Rather than quibbling about terminology, patients should be educated about the very real threat posed by persistent and untreated symptoms, Dr. Walkup suggested. Pathological anxiety, regardless of the term used, is not a phase.
“Some of these kids do recover from childhood onset anxiety, but more often, the condition tracks to adolescence or adulthood,” Dr. Walkup said. . He contended that many adults with personality disorders are experiencing the consequences of distorted thinking and problematic emotional responses that began with childhood anxiety.
“Children with anxiety need to learn to cope. If you medicate them to control the anxiety, it does not necessarily mean that they will learn how to live anxiety free,” Dr. Walkup said, reiterating that pathological anxiety often persists indefinitely even after effective therapy diminishes the symptom burden. To improve a supportive family environment for an anxious child, he encouraged educating parents about the condition.
“One of the many books published on childhood anxiety may be all they need,” said Dr. Walkup, listing several examples, such as “You and Your Anxious Child” (New York: Avery, 2013) coauthored by Anne Marie Albano, PhD, a professor of child psychiatry at Columbia University in New York.
As anxiety is such a ubiquitous human experience, many parents trivialize the pathological variety, Dr. Walkup said. Educating patients about the immediate and long-term risks of pathological anxiety is important. The associated symptoms are not a phase, as some parents are likely to contend. He believes that early diagnosis and effective management can change the trajectory of a lifelong threat.
Dr. Walkup reported no potential conflicts of interest.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Latest PANS trials suggest cause may be treatable
NEW YORK – New controlled trials in the treatment of pediatric acute neuropsychiatric syndrome (PANS) support the hypothesis that the cause may, in fact, be treatable, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are controversial diagnoses. But ongoing research has expanded the body of literature describing symptoms and evaluating treatments, according to an overview from Barbara J. Coffey, MD, division chief in child and adolescent psychiatry at the University of Miami.
PANS and PANDAS, which are clinical diagnoses of exclusion, are characterized by an abrupt onset of one or more neuropsychiatric symptoms in children that can include signs of obsessive-compulsive disorder (OCD), tics, anxiety, irritability, and behavioral changes. Despite more than 15 years of clinical and experimental studies, almost all aspects of PANS and PANDAS remain controversial, Dr. Coffey said.
“Many pediatricians I work with do not want to see these kids, because they really do not know what to do,” she reported.
This prevailing conception has led to treatment trials with antibiotics for the underlying infection and, most recently, with intravenous immunoglobulins (IVIG) to prevent cross-reactive antibodies induced by infection. Dr. Coffey, reviewing several recently published studies, noted that there have been signals of activity suggesting “there may be something there.” However, she cautioned that the data are inconclusive.
Of recent studies, a trial with azithromycin in children with PANS generated somewhat positive findings (J Child Adolesc Psychopharmacol. 2017;27[7]:640-51). In this study, 31 children aged 4-14 years were randomized to receive azithromycin or placebo for 4 weeks. They were evaluated via the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) and the OCD Clinical Global Impression Severity (CGI-S OCD) scale.
The study associated azithromycin with a significant reduction in symptoms as measured with CGI-S OCD (41.2% vs. 7.1%; P = .045), but no difference was found in response as measured with the CY-BOCS, which Dr. Coffey described as the more conservative measure. Even when measured with the CGI-S OCD scale, symptom improvements were modest. But the authors concluded that azithromycin “may be helpful” for the control of neuropsychiatric symptoms.
In a trial with IVIG, 35 children with PANDAS were randomized to IVIG or placebo (J Am Acad Child Adolesc Psychiatry. 2016;55[10]:860-7). The primary outcome was at least a 30% reduction in CY-BOCS at 12 weeks. Nonresponders at 12 weeks were permitted 12 more weeks of treatment with open-label IVIG.
Twice as many patients receiving IVIG, compared with those on placebo, reached the primary outcome (24% vs. 12%), but the study was small and the difference did not reach significance. However, the authors reported that the mean CY-BOCS improvement from baseline on IVIG, which was well tolerated, was 55% at week 12 and 62% at week 24. The authors suggested that larger trials are warranted.
“One critique of this study is that all of the patients were placed on prophylactic antibiotics, which may have attenuated the response,” Dr. Coffey said. In outlining these results, she emphasized: “This is not something I am recommending. I just want to acquaint you with what is going on out there.”
None of the most recent trials provide conclusive support for therapy targeted at infection or an autoimmune process in PANS or PANDAS, but Dr. Coffey indicated that . One of the most recent sets of data come from a recently published Scandinavian cohort study with 17 years of follow-up (JAMA Psychiatry. 2017;74[7]:740-6). That study associated pediatric infections of any kind, not just streptococcal infections, with an elevated risk of mental disorders – particularly OCD and tics.
Overall, the evidence base is growing to suggest “antibiotics and immune therapy may be beneficial, but the jury is not in yet for which patients, how much, and how long,” Dr. Coffey said. She is aware of clinicians who are now using antibiotics empirically to control neuropsychiatric symptoms in PANDAS but cautioned that more investigation is needed.
Dr. Coffey reports financial relationships with Genco Sciences, Neurocrine Biosciences, Shire, and Teva/Nuvelution.
NEW YORK – New controlled trials in the treatment of pediatric acute neuropsychiatric syndrome (PANS) support the hypothesis that the cause may, in fact, be treatable, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are controversial diagnoses. But ongoing research has expanded the body of literature describing symptoms and evaluating treatments, according to an overview from Barbara J. Coffey, MD, division chief in child and adolescent psychiatry at the University of Miami.
PANS and PANDAS, which are clinical diagnoses of exclusion, are characterized by an abrupt onset of one or more neuropsychiatric symptoms in children that can include signs of obsessive-compulsive disorder (OCD), tics, anxiety, irritability, and behavioral changes. Despite more than 15 years of clinical and experimental studies, almost all aspects of PANS and PANDAS remain controversial, Dr. Coffey said.
“Many pediatricians I work with do not want to see these kids, because they really do not know what to do,” she reported.
This prevailing conception has led to treatment trials with antibiotics for the underlying infection and, most recently, with intravenous immunoglobulins (IVIG) to prevent cross-reactive antibodies induced by infection. Dr. Coffey, reviewing several recently published studies, noted that there have been signals of activity suggesting “there may be something there.” However, she cautioned that the data are inconclusive.
Of recent studies, a trial with azithromycin in children with PANS generated somewhat positive findings (J Child Adolesc Psychopharmacol. 2017;27[7]:640-51). In this study, 31 children aged 4-14 years were randomized to receive azithromycin or placebo for 4 weeks. They were evaluated via the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) and the OCD Clinical Global Impression Severity (CGI-S OCD) scale.
The study associated azithromycin with a significant reduction in symptoms as measured with CGI-S OCD (41.2% vs. 7.1%; P = .045), but no difference was found in response as measured with the CY-BOCS, which Dr. Coffey described as the more conservative measure. Even when measured with the CGI-S OCD scale, symptom improvements were modest. But the authors concluded that azithromycin “may be helpful” for the control of neuropsychiatric symptoms.
In a trial with IVIG, 35 children with PANDAS were randomized to IVIG or placebo (J Am Acad Child Adolesc Psychiatry. 2016;55[10]:860-7). The primary outcome was at least a 30% reduction in CY-BOCS at 12 weeks. Nonresponders at 12 weeks were permitted 12 more weeks of treatment with open-label IVIG.
Twice as many patients receiving IVIG, compared with those on placebo, reached the primary outcome (24% vs. 12%), but the study was small and the difference did not reach significance. However, the authors reported that the mean CY-BOCS improvement from baseline on IVIG, which was well tolerated, was 55% at week 12 and 62% at week 24. The authors suggested that larger trials are warranted.
“One critique of this study is that all of the patients were placed on prophylactic antibiotics, which may have attenuated the response,” Dr. Coffey said. In outlining these results, she emphasized: “This is not something I am recommending. I just want to acquaint you with what is going on out there.”
None of the most recent trials provide conclusive support for therapy targeted at infection or an autoimmune process in PANS or PANDAS, but Dr. Coffey indicated that . One of the most recent sets of data come from a recently published Scandinavian cohort study with 17 years of follow-up (JAMA Psychiatry. 2017;74[7]:740-6). That study associated pediatric infections of any kind, not just streptococcal infections, with an elevated risk of mental disorders – particularly OCD and tics.
Overall, the evidence base is growing to suggest “antibiotics and immune therapy may be beneficial, but the jury is not in yet for which patients, how much, and how long,” Dr. Coffey said. She is aware of clinicians who are now using antibiotics empirically to control neuropsychiatric symptoms in PANDAS but cautioned that more investigation is needed.
Dr. Coffey reports financial relationships with Genco Sciences, Neurocrine Biosciences, Shire, and Teva/Nuvelution.
NEW YORK – New controlled trials in the treatment of pediatric acute neuropsychiatric syndrome (PANS) support the hypothesis that the cause may, in fact, be treatable, an expert said at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
PANS and pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are controversial diagnoses. But ongoing research has expanded the body of literature describing symptoms and evaluating treatments, according to an overview from Barbara J. Coffey, MD, division chief in child and adolescent psychiatry at the University of Miami.
PANS and PANDAS, which are clinical diagnoses of exclusion, are characterized by an abrupt onset of one or more neuropsychiatric symptoms in children that can include signs of obsessive-compulsive disorder (OCD), tics, anxiety, irritability, and behavioral changes. Despite more than 15 years of clinical and experimental studies, almost all aspects of PANS and PANDAS remain controversial, Dr. Coffey said.
“Many pediatricians I work with do not want to see these kids, because they really do not know what to do,” she reported.
This prevailing conception has led to treatment trials with antibiotics for the underlying infection and, most recently, with intravenous immunoglobulins (IVIG) to prevent cross-reactive antibodies induced by infection. Dr. Coffey, reviewing several recently published studies, noted that there have been signals of activity suggesting “there may be something there.” However, she cautioned that the data are inconclusive.
Of recent studies, a trial with azithromycin in children with PANS generated somewhat positive findings (J Child Adolesc Psychopharmacol. 2017;27[7]:640-51). In this study, 31 children aged 4-14 years were randomized to receive azithromycin or placebo for 4 weeks. They were evaluated via the Children’s Yale–Brown Obsessive Compulsive Scale (CY-BOCS) and the OCD Clinical Global Impression Severity (CGI-S OCD) scale.
The study associated azithromycin with a significant reduction in symptoms as measured with CGI-S OCD (41.2% vs. 7.1%; P = .045), but no difference was found in response as measured with the CY-BOCS, which Dr. Coffey described as the more conservative measure. Even when measured with the CGI-S OCD scale, symptom improvements were modest. But the authors concluded that azithromycin “may be helpful” for the control of neuropsychiatric symptoms.
In a trial with IVIG, 35 children with PANDAS were randomized to IVIG or placebo (J Am Acad Child Adolesc Psychiatry. 2016;55[10]:860-7). The primary outcome was at least a 30% reduction in CY-BOCS at 12 weeks. Nonresponders at 12 weeks were permitted 12 more weeks of treatment with open-label IVIG.
Twice as many patients receiving IVIG, compared with those on placebo, reached the primary outcome (24% vs. 12%), but the study was small and the difference did not reach significance. However, the authors reported that the mean CY-BOCS improvement from baseline on IVIG, which was well tolerated, was 55% at week 12 and 62% at week 24. The authors suggested that larger trials are warranted.
“One critique of this study is that all of the patients were placed on prophylactic antibiotics, which may have attenuated the response,” Dr. Coffey said. In outlining these results, she emphasized: “This is not something I am recommending. I just want to acquaint you with what is going on out there.”
None of the most recent trials provide conclusive support for therapy targeted at infection or an autoimmune process in PANS or PANDAS, but Dr. Coffey indicated that . One of the most recent sets of data come from a recently published Scandinavian cohort study with 17 years of follow-up (JAMA Psychiatry. 2017;74[7]:740-6). That study associated pediatric infections of any kind, not just streptococcal infections, with an elevated risk of mental disorders – particularly OCD and tics.
Overall, the evidence base is growing to suggest “antibiotics and immune therapy may be beneficial, but the jury is not in yet for which patients, how much, and how long,” Dr. Coffey said. She is aware of clinicians who are now using antibiotics empirically to control neuropsychiatric symptoms in PANDAS but cautioned that more investigation is needed.
Dr. Coffey reports financial relationships with Genco Sciences, Neurocrine Biosciences, Shire, and Teva/Nuvelution.
REPORTING FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Psychiatric pharmacogenomics not ‘ready for prime time’
NEW YORK – Pharmacogenomics testing for guiding drug choices in psychiatric disease is “not completely ready for prime time,” based on a critical review of published guidelines and expert opinions on the use of those tests, according to Erika L. Nurmi, MD, PhD.
It is important to understand the limitations of such tests because many patients or family members are asking clinicians to be guided by the results of tests they have ordered on their own, said Dr. Nurmi, a researcher and clinician at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.
Published guidelines and expert opinions based on objective data support these conclusions, she said. Dr. Nurmi suggested that .
“Basically, what it says is if you do not have the testing in hand, don’t order it. If you have the testing in hand when a poor metabolizer of CYP2D6 or CYP2C19 has been identified, switch to a med that is not metabolized by those enzymes. That’s it,” Dr. Nurmi reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC) were only modestly more detailed. Only a moderate level of evidence supported most recommendations, she said, and these were labeled optional. The exception regarded treating ultrafast metabolizers of CYP2D6 who are taking paroxetine: In these, the use of a drug metabolized by a different enzyme was strongly recommended.
Similar recommendations in the CPIC guidelines were made for fluoxetine, fluvoxamine, and sertraline. In patients on citalopram or escitalopram, ultrafast metabolizers of CYP2C19 are considered candidates for a non-CYP2C19 drug. If they are poor metabolizers, the CPIC guidelines recommended a non-CYP2C19 drug or reducing the starting dose by 50%.
However, in all of these cases, pharmacogenomics testing is best reserved for patients who have had an inadequate response to therapy or, in the case of poor metabolizers, have had unacceptable adverse events.
Of the limitations Dr. Nurmi outlined for pharmacogenomics testing, one of the most important is that these tests typically focus on a single genetic variant. According to Dr. Nurmi, the problem with a single variant is that “our bodies are more complex.” She said she believes that genetic information for drug selection will not be useful until testing is able to synthesize information from multiple genetic variants and place this in context with confounders such as age and exposure to other substances, such as hormones, caffeine, or grapefruit juice.
This complexity is likely to be mastered eventually, Dr. Nurmi said, but patients now have unrealistic expectations. For their part, clinicians need to develop an understanding of the limitations of these tests in order to provide informed counsel. As pharmacogenomics testing is being marketed directly to consumers with inflated claims about its value, clinicians often must defend their decision to use or not use this information.
“Commercially available products combine variants of widely discrepant validity using proprietary, undisclosed algorithms into sweeping treatment recommendations,” said Dr. Nurmi, who noted that she has found some of her own data misappropriated to make claims. Often, the companies that develop the tests have conducted the validation studies without any replication by independent investigators. She noted that many studies have been declared positive on the basis of secondary outcomes after the primary outcome was negative.
“There are very few positive prospective, randomized, double-blind trials,” Dr. Nurmi said. Even when such trials have been conducted, they typically are not designed to show a clinically meaningful outcome.
By attempting to look at a single or a limited number of variants in which to guide choice of medication in psychiatric disease, pharmacogenomics testing is being “vastly oversimplified,” Dr. Nurmi said. Although she said she believes this field is enormously promising and that medical records for each patient eventually will contain the genome sequence, she emphasized that, at this time, pharmacogenomics testing has a very limited role to play for the management of psychiatric diseases.
Dr. Nurmi reported she had no financial relationships relevant to this topic.
NEW YORK – Pharmacogenomics testing for guiding drug choices in psychiatric disease is “not completely ready for prime time,” based on a critical review of published guidelines and expert opinions on the use of those tests, according to Erika L. Nurmi, MD, PhD.
It is important to understand the limitations of such tests because many patients or family members are asking clinicians to be guided by the results of tests they have ordered on their own, said Dr. Nurmi, a researcher and clinician at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.
Published guidelines and expert opinions based on objective data support these conclusions, she said. Dr. Nurmi suggested that .
“Basically, what it says is if you do not have the testing in hand, don’t order it. If you have the testing in hand when a poor metabolizer of CYP2D6 or CYP2C19 has been identified, switch to a med that is not metabolized by those enzymes. That’s it,” Dr. Nurmi reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC) were only modestly more detailed. Only a moderate level of evidence supported most recommendations, she said, and these were labeled optional. The exception regarded treating ultrafast metabolizers of CYP2D6 who are taking paroxetine: In these, the use of a drug metabolized by a different enzyme was strongly recommended.
Similar recommendations in the CPIC guidelines were made for fluoxetine, fluvoxamine, and sertraline. In patients on citalopram or escitalopram, ultrafast metabolizers of CYP2C19 are considered candidates for a non-CYP2C19 drug. If they are poor metabolizers, the CPIC guidelines recommended a non-CYP2C19 drug or reducing the starting dose by 50%.
However, in all of these cases, pharmacogenomics testing is best reserved for patients who have had an inadequate response to therapy or, in the case of poor metabolizers, have had unacceptable adverse events.
Of the limitations Dr. Nurmi outlined for pharmacogenomics testing, one of the most important is that these tests typically focus on a single genetic variant. According to Dr. Nurmi, the problem with a single variant is that “our bodies are more complex.” She said she believes that genetic information for drug selection will not be useful until testing is able to synthesize information from multiple genetic variants and place this in context with confounders such as age and exposure to other substances, such as hormones, caffeine, or grapefruit juice.
This complexity is likely to be mastered eventually, Dr. Nurmi said, but patients now have unrealistic expectations. For their part, clinicians need to develop an understanding of the limitations of these tests in order to provide informed counsel. As pharmacogenomics testing is being marketed directly to consumers with inflated claims about its value, clinicians often must defend their decision to use or not use this information.
“Commercially available products combine variants of widely discrepant validity using proprietary, undisclosed algorithms into sweeping treatment recommendations,” said Dr. Nurmi, who noted that she has found some of her own data misappropriated to make claims. Often, the companies that develop the tests have conducted the validation studies without any replication by independent investigators. She noted that many studies have been declared positive on the basis of secondary outcomes after the primary outcome was negative.
“There are very few positive prospective, randomized, double-blind trials,” Dr. Nurmi said. Even when such trials have been conducted, they typically are not designed to show a clinically meaningful outcome.
By attempting to look at a single or a limited number of variants in which to guide choice of medication in psychiatric disease, pharmacogenomics testing is being “vastly oversimplified,” Dr. Nurmi said. Although she said she believes this field is enormously promising and that medical records for each patient eventually will contain the genome sequence, she emphasized that, at this time, pharmacogenomics testing has a very limited role to play for the management of psychiatric diseases.
Dr. Nurmi reported she had no financial relationships relevant to this topic.
NEW YORK – Pharmacogenomics testing for guiding drug choices in psychiatric disease is “not completely ready for prime time,” based on a critical review of published guidelines and expert opinions on the use of those tests, according to Erika L. Nurmi, MD, PhD.
It is important to understand the limitations of such tests because many patients or family members are asking clinicians to be guided by the results of tests they have ordered on their own, said Dr. Nurmi, a researcher and clinician at the UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles.
Published guidelines and expert opinions based on objective data support these conclusions, she said. Dr. Nurmi suggested that .
“Basically, what it says is if you do not have the testing in hand, don’t order it. If you have the testing in hand when a poor metabolizer of CYP2D6 or CYP2C19 has been identified, switch to a med that is not metabolized by those enzymes. That’s it,” Dr. Nurmi reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry.
The guidelines from the Clinical Pharmacogenetics Implementation Consortium (CPIC) were only modestly more detailed. Only a moderate level of evidence supported most recommendations, she said, and these were labeled optional. The exception regarded treating ultrafast metabolizers of CYP2D6 who are taking paroxetine: In these, the use of a drug metabolized by a different enzyme was strongly recommended.
Similar recommendations in the CPIC guidelines were made for fluoxetine, fluvoxamine, and sertraline. In patients on citalopram or escitalopram, ultrafast metabolizers of CYP2C19 are considered candidates for a non-CYP2C19 drug. If they are poor metabolizers, the CPIC guidelines recommended a non-CYP2C19 drug or reducing the starting dose by 50%.
However, in all of these cases, pharmacogenomics testing is best reserved for patients who have had an inadequate response to therapy or, in the case of poor metabolizers, have had unacceptable adverse events.
Of the limitations Dr. Nurmi outlined for pharmacogenomics testing, one of the most important is that these tests typically focus on a single genetic variant. According to Dr. Nurmi, the problem with a single variant is that “our bodies are more complex.” She said she believes that genetic information for drug selection will not be useful until testing is able to synthesize information from multiple genetic variants and place this in context with confounders such as age and exposure to other substances, such as hormones, caffeine, or grapefruit juice.
This complexity is likely to be mastered eventually, Dr. Nurmi said, but patients now have unrealistic expectations. For their part, clinicians need to develop an understanding of the limitations of these tests in order to provide informed counsel. As pharmacogenomics testing is being marketed directly to consumers with inflated claims about its value, clinicians often must defend their decision to use or not use this information.
“Commercially available products combine variants of widely discrepant validity using proprietary, undisclosed algorithms into sweeping treatment recommendations,” said Dr. Nurmi, who noted that she has found some of her own data misappropriated to make claims. Often, the companies that develop the tests have conducted the validation studies without any replication by independent investigators. She noted that many studies have been declared positive on the basis of secondary outcomes after the primary outcome was negative.
“There are very few positive prospective, randomized, double-blind trials,” Dr. Nurmi said. Even when such trials have been conducted, they typically are not designed to show a clinically meaningful outcome.
By attempting to look at a single or a limited number of variants in which to guide choice of medication in psychiatric disease, pharmacogenomics testing is being “vastly oversimplified,” Dr. Nurmi said. Although she said she believes this field is enormously promising and that medical records for each patient eventually will contain the genome sequence, she emphasized that, at this time, pharmacogenomics testing has a very limited role to play for the management of psychiatric diseases.
Dr. Nurmi reported she had no financial relationships relevant to this topic.
EXPERT ANALYSIS FROM THE PSYCHOPHARMACOLOGY UPDATE INSTITUTE
Abrupt behavior changes in autism? ID medical triggers first
NEW YORK – When treating children with autism spectrum disorder who develop an abrupt increase in symptoms, it is best to identify and treat the precipitating event or events – rather than intensify ASD drug therapy, an expert said.
“These acute behavior changes are almost always triggered by something,” Jeremy Veenstra-VanderWeele, MD, reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. Triggers are not always identifiable, but Dr. Veenstra-VanderWeele said solutions may prove simple when they are.
In ASD patients with an acute change in behavior, caregivers typically think first of environmental triggers, including adverse interactions with peers or siblings. But Dr. Veenstra-VanderWeele emphasized that medical problems should be considered first. This makes sense because of the importance of quickly resolving health problems. However, pain and discomfort, particularly in those with difficulty verbalizing these complaints, can be overlooked.
Moreover, even highly verbal ASD patients may not volunteer physical complaints without prompting, Dr. Veenstra-VanderWeele said. Among the health issues in children, constipation and other gastrointestinal issues are “incredibly common” in ASD patients. Dr. Veenstra-VanderWeele looks for clues, such as body posturing suggesting abdominal pain or flatulence, when a history is ambiguous.
“I will order an abdominal flat plate when I hear enough symptoms to make me wonder when the family is not sure,” Dr. Veenstra-VanderWeele reported. “Almost always it comes back with evidence of constipation. We treat it, and they are less irritable like all of us would be.”
All common conditions in a pediatric population, including ear infections, dental caries, and food allergies, should be considered, according to Dr. Veenstra-VanderWeele, who recommended a practice pathway for evaluating triggers in children with ASD (Pediatrics. 2016 Feb;137 Suppl 2:S136-48). A coauthor on this pathway, Dr. Veenstra-VanderWeele emphasized the importance of pursuing a systematic approach to medical issues before considering other triggers, such as psychosocial stressors.
In adolescents, headache caused by migraine and late-onset epilepsy, often in the form of complex partial seizures, should be added to the list of potential triggers for irritation or aggression, Dr. Veenstra-VanderWeele said. Epilepsy often precedes the diagnosis of ASD in young children, and Dr. Veenstra-VanderWeele noted that a second peak incidence sometimes occurs in late adolescence.
After ruling out medical problems, helping patients recognize and verbalize stressors can serve as both diagnosis and treatment. In ASD patients with limited verbal skills who are suffering from stress, “aggression is one form of communication,” Dr. Veenstra-VanderWeele said.
However, Dr. Veenstra-VanderWeele cautioned that, even if a trigger is successfully addressed, inadvertently reinforced aggression might persist.
“Aggression can be rewarded sometimes by removing the patient from the classroom, sometimes by giving in, and then that becomes a maladaptive reinforcement pattern that needs to be broken,” Dr. Veenstra-VanderWeele said. “Even if you are treating their irritability and agitation with, say, risperidone, you still need to break the maladaptive reinforcement pattern or they will keep engaging in what has become instrumental aggression.”
Dr. Veenstra-VanderWeele reported financial relationships with Hoffmann-La Roche, Novartis, Seaside Therapeutics, and SynapDx.
NEW YORK – When treating children with autism spectrum disorder who develop an abrupt increase in symptoms, it is best to identify and treat the precipitating event or events – rather than intensify ASD drug therapy, an expert said.
“These acute behavior changes are almost always triggered by something,” Jeremy Veenstra-VanderWeele, MD, reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. Triggers are not always identifiable, but Dr. Veenstra-VanderWeele said solutions may prove simple when they are.
In ASD patients with an acute change in behavior, caregivers typically think first of environmental triggers, including adverse interactions with peers or siblings. But Dr. Veenstra-VanderWeele emphasized that medical problems should be considered first. This makes sense because of the importance of quickly resolving health problems. However, pain and discomfort, particularly in those with difficulty verbalizing these complaints, can be overlooked.
Moreover, even highly verbal ASD patients may not volunteer physical complaints without prompting, Dr. Veenstra-VanderWeele said. Among the health issues in children, constipation and other gastrointestinal issues are “incredibly common” in ASD patients. Dr. Veenstra-VanderWeele looks for clues, such as body posturing suggesting abdominal pain or flatulence, when a history is ambiguous.
“I will order an abdominal flat plate when I hear enough symptoms to make me wonder when the family is not sure,” Dr. Veenstra-VanderWeele reported. “Almost always it comes back with evidence of constipation. We treat it, and they are less irritable like all of us would be.”
All common conditions in a pediatric population, including ear infections, dental caries, and food allergies, should be considered, according to Dr. Veenstra-VanderWeele, who recommended a practice pathway for evaluating triggers in children with ASD (Pediatrics. 2016 Feb;137 Suppl 2:S136-48). A coauthor on this pathway, Dr. Veenstra-VanderWeele emphasized the importance of pursuing a systematic approach to medical issues before considering other triggers, such as psychosocial stressors.
In adolescents, headache caused by migraine and late-onset epilepsy, often in the form of complex partial seizures, should be added to the list of potential triggers for irritation or aggression, Dr. Veenstra-VanderWeele said. Epilepsy often precedes the diagnosis of ASD in young children, and Dr. Veenstra-VanderWeele noted that a second peak incidence sometimes occurs in late adolescence.
After ruling out medical problems, helping patients recognize and verbalize stressors can serve as both diagnosis and treatment. In ASD patients with limited verbal skills who are suffering from stress, “aggression is one form of communication,” Dr. Veenstra-VanderWeele said.
However, Dr. Veenstra-VanderWeele cautioned that, even if a trigger is successfully addressed, inadvertently reinforced aggression might persist.
“Aggression can be rewarded sometimes by removing the patient from the classroom, sometimes by giving in, and then that becomes a maladaptive reinforcement pattern that needs to be broken,” Dr. Veenstra-VanderWeele said. “Even if you are treating their irritability and agitation with, say, risperidone, you still need to break the maladaptive reinforcement pattern or they will keep engaging in what has become instrumental aggression.”
Dr. Veenstra-VanderWeele reported financial relationships with Hoffmann-La Roche, Novartis, Seaside Therapeutics, and SynapDx.
NEW YORK – When treating children with autism spectrum disorder who develop an abrupt increase in symptoms, it is best to identify and treat the precipitating event or events – rather than intensify ASD drug therapy, an expert said.
“These acute behavior changes are almost always triggered by something,” Jeremy Veenstra-VanderWeele, MD, reported at a pediatric psychopharmacology update held by the American Academy of Child and Adolescent Psychiatry. Triggers are not always identifiable, but Dr. Veenstra-VanderWeele said solutions may prove simple when they are.
In ASD patients with an acute change in behavior, caregivers typically think first of environmental triggers, including adverse interactions with peers or siblings. But Dr. Veenstra-VanderWeele emphasized that medical problems should be considered first. This makes sense because of the importance of quickly resolving health problems. However, pain and discomfort, particularly in those with difficulty verbalizing these complaints, can be overlooked.
Moreover, even highly verbal ASD patients may not volunteer physical complaints without prompting, Dr. Veenstra-VanderWeele said. Among the health issues in children, constipation and other gastrointestinal issues are “incredibly common” in ASD patients. Dr. Veenstra-VanderWeele looks for clues, such as body posturing suggesting abdominal pain or flatulence, when a history is ambiguous.
“I will order an abdominal flat plate when I hear enough symptoms to make me wonder when the family is not sure,” Dr. Veenstra-VanderWeele reported. “Almost always it comes back with evidence of constipation. We treat it, and they are less irritable like all of us would be.”
All common conditions in a pediatric population, including ear infections, dental caries, and food allergies, should be considered, according to Dr. Veenstra-VanderWeele, who recommended a practice pathway for evaluating triggers in children with ASD (Pediatrics. 2016 Feb;137 Suppl 2:S136-48). A coauthor on this pathway, Dr. Veenstra-VanderWeele emphasized the importance of pursuing a systematic approach to medical issues before considering other triggers, such as psychosocial stressors.
In adolescents, headache caused by migraine and late-onset epilepsy, often in the form of complex partial seizures, should be added to the list of potential triggers for irritation or aggression, Dr. Veenstra-VanderWeele said. Epilepsy often precedes the diagnosis of ASD in young children, and Dr. Veenstra-VanderWeele noted that a second peak incidence sometimes occurs in late adolescence.
After ruling out medical problems, helping patients recognize and verbalize stressors can serve as both diagnosis and treatment. In ASD patients with limited verbal skills who are suffering from stress, “aggression is one form of communication,” Dr. Veenstra-VanderWeele said.
However, Dr. Veenstra-VanderWeele cautioned that, even if a trigger is successfully addressed, inadvertently reinforced aggression might persist.
“Aggression can be rewarded sometimes by removing the patient from the classroom, sometimes by giving in, and then that becomes a maladaptive reinforcement pattern that needs to be broken,” Dr. Veenstra-VanderWeele said. “Even if you are treating their irritability and agitation with, say, risperidone, you still need to break the maladaptive reinforcement pattern or they will keep engaging in what has become instrumental aggression.”
Dr. Veenstra-VanderWeele reported financial relationships with Hoffmann-La Roche, Novartis, Seaside Therapeutics, and SynapDx.
EXPERT ANALYSIS FROM the PSYCHOPHARMACOLOGY UPDATE INSTITUTE