APA 2011

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – Women whose depression improved during a 1-year treatment trial for metastatic breast cancer survived a median 2 years longer than women whose depression worsened, according to a long-term follow-up study.

"Our main finding is that the course of depression over the initial year of the study can be used to predict survival up to 14 years later," Dr. David Spiegel said at the annual meeting of the American Psychiatric Association.

Therefore, screen patients with breast cancer for depression. Also, do not dismiss depressive symptoms as merely a normal component of a cancer diagnosis or treatment, he said. Another clinical implication is that psychotherapy intervention can make a significant positive difference. "There are ways of facing and living with this disease that may help patients to live longer as well as better.

"This is a tremendous opportunity for psychiatry to be a part of the mission that is now mandated at cancer centers – to help cancer patients live better with their illness," said Dr. Spiegel, director of the center on stress and health at Stanford (Calif.) University.

One-quarter of cancer patients meet the criteria for depression, Dr. Spiegel said. "The more serious your medical illness, the more likely you are to be depressed. It’s 3% of the general population, 6% of outpatients, and 12% of medical inpatients – 1 out of 9 is depressed. But we often overlook the diagnosis; we misattribute the sadness to the prognosis of the disease; the disinterest in eating to the side effects of chemotherapy; the sleep disturbance to the worry about the illness.

"All of these can be signs of depression," he said.

Therefore, more awareness of an association between depression and a cancer prognosis is warranted. "Somehow people get the idea that if you have depression, it can worsen your prognosis with heart disease. But they have a much more difficult time understanding that ... depression is just as lethal a comorbid factor with cancer," Dr. Spiegel said.

He and his associates found median survival was 53.6 months for women whose baseline scores on the Center for Epidemiologic Studies–Depression Scale (CES-D) decreased over a period of 12 months, compared with a median 25.1-month survival for women whose CES-D scores increased. This 28.5-month difference in median survival was statistically significant.

The cohort included 101 women of 125 randomized to supportive-expressive group therapy or a control group with education materials who completed the CES-D scale at baseline and at three assessment points during the year (J. Clin. Oncol. 2011;29:413-20).

Only improvement in depression ratings, not treatment vs. no treatment, was associated with longer survival in this secondary analysis of the original study (Cancer 2007;110:1130-8).

Depression was an independent, long-term predictor of mortality. The researchers controlled for all the usual prognostic variables, including estrogen receptor and progesterone receptor status, disease-free interval, and age at diagnosis.

There is other evidence that psychotherapy can significantly reduce depressive symptoms in patients with advanced cancer, said Dr. Spiegel. For example, a Cochrane database analysis showed such a benefit in patients with incurable cancer who received supportive psychotherapy, cognitive-behavioral therapy, or problem-solving psychotherapy (Cochrane Database Syst. Rev. 2008;CD005537).

Dr. Spiegel said the psychotherapy in his study reduced patients’ tendency to suppress emotion. "So this outcome is not about distress; it’s about their management of distress. This, it turned out, mediated the reduction in depression and anxiety.

"We encourage people to face their fears of dying and death. We call it ‘detoxifying dying,’ " Dr. Spiegel said. Patients learn to face death, to reorder priorities, and to communicate better with families and physicians.

More support for an association between less depression and better outcomes for cancer patients emerged from a study of 107 patients with metastatic non–small cell lung cancer (N. Engl. J. Med. 2010:363:733-42). Fewer patients who received early palliative therapy reported depressive symptoms, 16%, vs. 38% of patients assigned to standard care. In addition, the early palliative care group had a longer median survival (11.6 months vs. 8.9 months). Both differences were statistically significant.

However, there is still no consensus in the literature about psychosocial intervention and cancer survival. Seven randomized trials now show a survival benefit, and six show no difference, Dr. Spiegel said. "The results are not random; I’m glad to say that no studies show that psychotherapy kills patients."

Although further research is warranted, Dr. Spiegel said, "it is now reasonable to raise the possibility that treating depression and other psychiatric aspects of cancer may not only help people live better, but may help them live longer."

The study was sponsored by the National Institute of Mental Health, the National Cancer Institute, and the National Institute on Aging. Dr. Spiegel is an editorial advisory board member to this news organization. He reported no other relevant financial disclosures.

HONOLULU – A survey of 178 older, mostly academic psychiatrists found that more than 6% text with patients, 20% post private information online, and 6% conduct an online search for patients.

Of those who post personal information on such social sites as Facebook, one-third do not restrict access; some are unaware of privacy settings that allow such restrictions.

Photo credit: ©DWP/Fotolia.com

About a third reported exchanging e-mails with patients as well, but only 7% get written permission first. "We found that half get verbal permission, but some never request permission [at all]. Only a small percent [have patients] sign a release form," although that’s been recommended, said senior investigator Dr. Megan Testa, a fourth-year psychiatry resident at the University Hospitals Health System in Cleveland, referring to guidelines released a few years ago by the American Medical Informatics Association Internet Working Group (J. Am. Med. Inform. Assoc. 1998;5:104-11).

The inconsistencies show that "we need a set of [electronic communication] guidelines" specific to psychiatrists, she said.

These guidelines are needed because social media can quickly blur boundaries between psychiatrists and patients, perhaps more so than with physicians in other specialties, given the interpersonal nature of the profession. "Legal issues, privacy issues, and treatment frame" issues are of particular concern, said Dr. Testa, a 2010 Group for the Advancement of Psychiatry fellow.

The 178 psychiatrists surveyed by Dr. Testa and her colleagues, also 2010 fellows, were all members of the psychiatry group. Their mean age was almost 60 years; 56% were academics, 41% in private practice, and the rest worked in other settings.

The 6% who admitted to looking up their patients online did so for a variety of reasons. Some needed to find contacts for patients who go to the emergency department and are unable to give reliable information. Others wanted to flesh out patient histories. "Sometimes," though, doctors "are curious if patients are lying," Dr. Testa said.

With doctors leaving bigger online footprints, "there is real concern [that] searches go both ways," she noted.

E-communications guidelines do exist for doctors. One set is for looking patients up online, and addresses getting consent, charting results, and sharing results with patients (Harv. Rev. Psychiatry 2010;18:103-12).

A set of social media guidelines discourages "friending" patients and freely posting personal information on sites like Facebook (J. Med. Ethics 2009;35:584-6).

Until psychiatrists come up with their own guidelines, Dr. Testa and her colleagues suggest, psychiatrists must "carefully monitor their online presences from medical school through residency and beyond to maintain a clear boundary between professional and personal identities."

HONOLULU – A survey of 178 older, mostly academic psychiatrists found that more than 6% text with patients, 20% post private information online, and 6% conduct an online search for patients.

Of those who post personal information on such social sites as Facebook, one-third do not restrict access; some are unaware of privacy settings that allow such restrictions.

Photo credit: ©DWP/Fotolia.com

About a third reported exchanging e-mails with patients as well, but only 7% get written permission first. "We found that half get verbal permission, but some never request permission [at all]. Only a small percent [have patients] sign a release form," although that’s been recommended, said senior investigator Dr. Megan Testa, a fourth-year psychiatry resident at the University Hospitals Health System in Cleveland, referring to guidelines released a few years ago by the American Medical Informatics Association Internet Working Group (J. Am. Med. Inform. Assoc. 1998;5:104-11).

The inconsistencies show that "we need a set of [electronic communication] guidelines" specific to psychiatrists, she said.

These guidelines are needed because social media can quickly blur boundaries between psychiatrists and patients, perhaps more so than with physicians in other specialties, given the interpersonal nature of the profession. "Legal issues, privacy issues, and treatment frame" issues are of particular concern, said Dr. Testa, a 2010 Group for the Advancement of Psychiatry fellow.

The 178 psychiatrists surveyed by Dr. Testa and her colleagues, also 2010 fellows, were all members of the psychiatry group. Their mean age was almost 60 years; 56% were academics, 41% in private practice, and the rest worked in other settings.

The 6% who admitted to looking up their patients online did so for a variety of reasons. Some needed to find contacts for patients who go to the emergency department and are unable to give reliable information. Others wanted to flesh out patient histories. "Sometimes," though, doctors "are curious if patients are lying," Dr. Testa said.

With doctors leaving bigger online footprints, "there is real concern [that] searches go both ways," she noted.

E-communications guidelines do exist for doctors. One set is for looking patients up online, and addresses getting consent, charting results, and sharing results with patients (Harv. Rev. Psychiatry 2010;18:103-12).

A set of social media guidelines discourages "friending" patients and freely posting personal information on sites like Facebook (J. Med. Ethics 2009;35:584-6).

Until psychiatrists come up with their own guidelines, Dr. Testa and her colleagues suggest, psychiatrists must "carefully monitor their online presences from medical school through residency and beyond to maintain a clear boundary between professional and personal identities."

HONOLULU – A survey of 178 older, mostly academic psychiatrists found that more than 6% text with patients, 20% post private information online, and 6% conduct an online search for patients.

Of those who post personal information on such social sites as Facebook, one-third do not restrict access; some are unaware of privacy settings that allow such restrictions.

Photo credit: ©DWP/Fotolia.com

About a third reported exchanging e-mails with patients as well, but only 7% get written permission first. "We found that half get verbal permission, but some never request permission [at all]. Only a small percent [have patients] sign a release form," although that’s been recommended, said senior investigator Dr. Megan Testa, a fourth-year psychiatry resident at the University Hospitals Health System in Cleveland, referring to guidelines released a few years ago by the American Medical Informatics Association Internet Working Group (J. Am. Med. Inform. Assoc. 1998;5:104-11).

The inconsistencies show that "we need a set of [electronic communication] guidelines" specific to psychiatrists, she said.

These guidelines are needed because social media can quickly blur boundaries between psychiatrists and patients, perhaps more so than with physicians in other specialties, given the interpersonal nature of the profession. "Legal issues, privacy issues, and treatment frame" issues are of particular concern, said Dr. Testa, a 2010 Group for the Advancement of Psychiatry fellow.

The 178 psychiatrists surveyed by Dr. Testa and her colleagues, also 2010 fellows, were all members of the psychiatry group. Their mean age was almost 60 years; 56% were academics, 41% in private practice, and the rest worked in other settings.

The 6% who admitted to looking up their patients online did so for a variety of reasons. Some needed to find contacts for patients who go to the emergency department and are unable to give reliable information. Others wanted to flesh out patient histories. "Sometimes," though, doctors "are curious if patients are lying," Dr. Testa said.

With doctors leaving bigger online footprints, "there is real concern [that] searches go both ways," she noted.

E-communications guidelines do exist for doctors. One set is for looking patients up online, and addresses getting consent, charting results, and sharing results with patients (Harv. Rev. Psychiatry 2010;18:103-12).

A set of social media guidelines discourages "friending" patients and freely posting personal information on sites like Facebook (J. Med. Ethics 2009;35:584-6).

Until psychiatrists come up with their own guidelines, Dr. Testa and her colleagues suggest, psychiatrists must "carefully monitor their online presences from medical school through residency and beyond to maintain a clear boundary between professional and personal identities."

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.

Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).

"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.

This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.

Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2013.

"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.

"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.

If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.

Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.

A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).

"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.

"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.

Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "

Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.

"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.

A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"

However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.

No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."

Some of these disorders, especially borderline, antisocial, and schizotypal, cause high rates of social and occupational impairment, Dr. Oldham said. "There is really an enormous impact on quality of life."

Dr. Oldham said he had no relevant disclosures.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – A statewide telepsychiatry consulting service in South Carolina shortened emergency department stays and reduced hospital admissions for more than 6,000 mental health patients. Those patients also used outpatient psychiatric services more, and their care was less expensive, said Dr. Stephanie R. Chapman at the annual meeting of the American Psychiatric Association.

Under the program, psychiatrists assess emergency department patients remotely via live video link. So far, 25 hospitals – none of which have readily available onsite psychiatric consulting services – are participating; the South Carolina Department of Mental Health plans to enroll 15 more within a year, according to Dr. Chapman, a psychiatry resident at the University of South Carolina, Columbia.

"In our state, we have so many mental health patients who are not receiving the care they need in the emergency room. A lot of facilities have no psychiatrists working in them. Someone has to drive in days later to see these patients," she said. "It’s a big problem. That is why this was initially implemented" in March 2009, she said.

When telepsychiatry is called for, a video cart is rolled into the patient’s room. At the other end of the feed is a psychiatrist in Charleston, Columbia, Aiken, or Greenville, S.C.

The patient and psychiatrist are able to see one another and talk over the link. The psychiatrist does the assessment over about 30 minutes, prepped beforehand with the patient’s history, lab results, and other findings.

Afterward, the psychiatrist might recommend hospitalization or set up an outpatient appointment through the local mental health department, Dr. Chapman said.

At present, the service is available 16 hours a day. Psychiatrists take turns manning the feed at offices in the four towns, usually in 8-hour shifts. When a shift ends in Aiken, for example, a psychiatrist in the Greenville office might pick up the feed.

To see how the program is doing, Dr. Chapman and her colleagues compared the 6,000-plus telepsychiatry patients’ outcomes with those for matched controls at hospitals not yet participating in the program.

About 8% of telepsychiatry patients were admitted, vs. 12% of control patients. With telepsychiatry, "we now have a more specialized person performing the consult" and perhaps making better calls on who needs to be hospitalized, Dr. Chapman said.

Emergency department stays averaged three days for telepsychiatry patients, but four days for controls. About 85% with severe mental illnesses in the telepsychiatry group had outpatient follow-up within 30 days, compared to 22% in the control group.

The program saves money, too. Medicaid telepsychiatry patients had median charges of $2,000; median charges were $2,800 among Medicaid patients in the control group. With other payer mixes, median charges for telepsychiatry patients were $6,800, vs. $11,000 for those in the control group.

Overall, about 80% of patients said they were satisfied with the service. About 90% of physicians said they were satisfied, too, and about three-quarters said telepsychiatry increased productivity.

In short, "the patient receives a higher quality of care, and the hospitals have reduced costs," Dr. Chapman and her colleagues concluded in their summary of the findings.

Dr. Chapman said she has no disclosures. The study was funded by the National Institute of Mental Health and the Duke Endowment.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.

HONOLULU – About 8% of U.S. veterans are problem gamblers who report between one and four gambling-related problems, and an additional 2% are pathological gamblers with five or more such problems, a study of 2,185 veterans in Department of Veterans Affairs care reveals.

Age, education level, and ethnicity were not big predictors of pathological gambling risk. "The one that does show a lot of difference is unemployment [odds ratio, 1.85], which is not necessarily what you expect. People need money to gamble, and they need a lot of money," Dr. Joseph J. Westermeyer IV said at the annual meeting of the American Psychiatric Association. The unemployed in the study, however, included part-time and seasonal workers who had some access to money, he said, and others were "homebodies" (typically unemployed men who were married to women with jobs).

(c) Tom Lozano/Creative Commons License

Marital status emerged as an important variable in a binary analysis, with unemployment remaining significant (OR, 1.41). "The folks who were divorced, separated, widowed, or single were underrepresented [OR, 0.69], so folks who were married were more likely to be in the problem and pathological gambling group. Again, this is not necessarily what you would expect," said Dr. Westermeyer, who is director of the mental health service at the Minneapolis VA Medical Center and professor of psychiatry at the University of Minnesota.

"Interestingly, male veterans and female veterans had almost identical rates of both problem gambling and pathological gambling, which is not – so far – what you see in the general population." Men usually outnumber women by a factor of two to three or more, Dr. Westermeyer said. It might be that the military exposes more women to gambling. "Some of the women we talked to say, ‘We hang around with the guys when we have time off. We don’t go to different places. We go to the same bars, and if they go gambling, we go gambling with them.’ "

The study included only veterans who were treated at least once in the previous 2 years at a VA facility. This design was intentional, so that any demographic or other risk factor that was identified would be relevant when incorporated into a future screening instrument.

Another aim was to identify comorbid symptoms "so primary care, as well as psychiatry, can begin to be alert to what might be associated with pathological gambling," Dr. Westermeyer said.

The veterans completed the SCL-90 (the 90-item Symptom Checklist instrument) and the PCL (PTSD [Posttraumatic Stress Disorder] Checklist). Their responses were directly and highly correlated with DSM-IV criteria and the South Oaks Gambling Screen. "In other words, people who have more posttraumatic symptoms, anxiety, and depression tend to have more gambling problems," Dr. Westermeyer said.

Participants also completed the AUDIT (Alcohol Use Disorders Identification Test) and the MAST (Michigan Alcohol Screening Test). The AUDIT addresses recent alcohol use and the MAST is a lifetime alcohol use measure, which was adapted to include drug use. Again, correlations were high. But in this study, people with more alcohol and drug problems tended to have fewer gambling problems, according to Dr. Westermeyer, which is contrary to other research that shows more substance problems associated with more gambling problems.

"All these findings tend to be a tad atypical," Dr. Westermeyer said.

The data were assessed in two different ways to reflect the current prevalence and to predict the future prevalence of problem and pathological gambling. For example, data were weighted to reflect the typical older male population that is seen at most VA centers today. Raw data included an oversampling of women (to bring the 7% in weighted data up to 35%) as well as younger veterans from the Iraq and Afghanistan conflicts (to reflect the way the VA population is likely to appear in a decade or two).

The weighted data show that veterans have about twice the rate of problem gambling as does the general population. The raw data suggest a greater disparity in the future, with a rate 2.7 times that of the general population.

The other worrisome thing about the future is the ratio of problem gamblers to pathological gamblers, Dr. Westermeyer said. General population surveys show a 1:1 ratio of problem gambling to pathological gambling among people who are exposed to gambling for a decade or more, and up to 2:1 with more recent exposure. "It’s worrisome with the veterans. The ratio is ... like four or five problem gamblers to one pathological gambler. The problem gamblers are the people at risk to become pathological gamblers ... which does not bode well for the future."

"Veterans in VA care have a high rate" of pathological gambling, he added.

All 10 DSM-IV gambling symptoms were assessed in the study. The sixth criteria (characterized in the DSM-IV as "chasing one’s losses") was the most common symptom, endorsed by 6.3% of participants with problem or pathological gambling. Tolerance was next at 5.1%, followed by escape gambling at 5.1%. The eighth criteria, which refers to committing illegal acts such as writing bad checks and committing property crimes, was the least commonly reported symptom, at just over 1%.

Another unexpected finding was a propensity for younger veterans to have higher scores on the South Oaks Gambling Screen for pathological gambling. "Most surveys that include people in their 20s rarely find a high prevalence [of pathological gambling], so ours was not a typical finding," said Dr. Westermeyer. Those who show up on the survey data tend to be people aged 35 years and older, he noted.

Participants were paid $20 to complete 2 hours of computer-based data collection; a research assistant was on hand to answer any questions. Participants were recruited at two VA medical centers and 14 rural community-based outpatient clinics.

This was a clinical epidemiologic study and not community-based research, a potential limitation.

Unanswered questions remain, Dr. Westermeyer said. Do these high rates among veterans in VA care reflect rates among all veterans? Also, would it be possible to identify earlier cases through screening?

The study was funded by VA Health Services Research & Development. Dr. Westermeyer said he had no relevant disclosures.