APA 2015

TORONTO – Consistent public education about the importance of treating first-episode psychosis in people aged 15-25 years results in better outcomes and quality of life for those on the schizophrenia spectrum, according to Dr. Brian O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne.

When the duration between the first episode and treatment-seeking is minimized, the time to the next episode is longer, according to Dr. O’Donoghue, who spoke at the annual meeting of the American Psychiatric Association.

In this video, Dr. O’Donoghue shares his experiences in creating public awareness about the frequency of first-episode psychosis in young people and the improved quality of life that results when communities ensure that support for this cohort is available.

[email protected]

On Twitter @whitneymcknight

TORONTO – Consistent public education about the importance of treating first-episode psychosis in people aged 15-25 years results in better outcomes and quality of life for those on the schizophrenia spectrum, according to Dr. Brian O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne.

When the duration between the first episode and treatment-seeking is minimized, the time to the next episode is longer, according to Dr. O’Donoghue, who spoke at the annual meeting of the American Psychiatric Association.

In this video, Dr. O’Donoghue shares his experiences in creating public awareness about the frequency of first-episode psychosis in young people and the improved quality of life that results when communities ensure that support for this cohort is available.

[email protected]

On Twitter @whitneymcknight

TORONTO – Consistent public education about the importance of treating first-episode psychosis in people aged 15-25 years results in better outcomes and quality of life for those on the schizophrenia spectrum, according to Dr. Brian O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne.

When the duration between the first episode and treatment-seeking is minimized, the time to the next episode is longer, according to Dr. O’Donoghue, who spoke at the annual meeting of the American Psychiatric Association.

In this video, Dr. O’Donoghue shares his experiences in creating public awareness about the frequency of first-episode psychosis in young people and the improved quality of life that results when communities ensure that support for this cohort is available.

[email protected]

On Twitter @whitneymcknight

TORONTO – Less than 10% of adults with any form of substance use disorders ever receive treatment, according to Dr. Shelly F. Greenfield, director of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass.

“Most patients won’t disclose their substance use unless they are asked,” Dr. Greenfield says in this video, recorded at the annual meeting of the American Psychiatric Association.

Screening all patients is particularly important, according to Dr. Greenfield, who says the patients you are least likely to suspect are often the ones who need help the most.

[email protected]

On Twitter @whitneymcknight

TORONTO – Less than 10% of adults with any form of substance use disorders ever receive treatment, according to Dr. Shelly F. Greenfield, director of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass.

“Most patients won’t disclose their substance use unless they are asked,” Dr. Greenfield says in this video, recorded at the annual meeting of the American Psychiatric Association.

Screening all patients is particularly important, according to Dr. Greenfield, who says the patients you are least likely to suspect are often the ones who need help the most.

[email protected]

On Twitter @whitneymcknight

TORONTO – Less than 10% of adults with any form of substance use disorders ever receive treatment, according to Dr. Shelly F. Greenfield, director of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass.

“Most patients won’t disclose their substance use unless they are asked,” Dr. Greenfield says in this video, recorded at the annual meeting of the American Psychiatric Association.

Screening all patients is particularly important, according to Dr. Greenfield, who says the patients you are least likely to suspect are often the ones who need help the most.

[email protected]

On Twitter @whitneymcknight

TORONTO – All patients, regardless of presentation, should be screened for substance abuse, according to an expert, but barriers such as shame and fear often make an accurate assessment difficult.

“Using a warm, empathetic, nonjudgmental style can help,” Dr. Shelly F. Greenfield told an audience at this year’s American Psychiatric Association meeting.

More than 9% of the U.S. population aged 12 years or older use an illicit substance, including marijuana and opioids in the previous month, according to data from the 2013 National Survey on Drug Use and Health. Among the illicit drug users, more than 80% used marijuana. Nearly a quarter of people aged 12 or older were binge alcohol users, defined as having five or more alcoholic drinks on at least 1 day in the 30 days before the survey was conducted.

Early detection and intervention can help prevent more serious substance use issues that often co-occur with psychiatric comorbidities such as depression or anxiety, said Dr. Greenfield, an addiction psychiatrist with the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The overall goal, she said, is to “formulate the problem, educate the patient, and help him or her initiate appropriate interventions and treatment.”

Physicians should understand that there are very real barriers for many patients who may be unwilling to endorse signs of any substance use. “Some could have legal concerns, such as how revealing any information could impact child custody, for example,” Dr. Greenfield said. Often, patients will deny, minimize, or rationalize their use. Using open-ended interviewing techniques, such as those used in motivational interviewing, can help the clinician see how the patient is defining the problem. Questions that allow patients to frame actions in their own words can help avoid confrontation, reduce ambivalence, and prompt patients to consider a rationale for changing their behavior (Patient Educ. Couns. 2013;93:157-68).

For example, physicians could use a prompt such as, “I wonder if you could tell me about your pattern of use of alcohol in a typical week ...” This information could then be a starting point for discussing the patient’s drinking habits according to the Timeline Followback Method, where patients reconstruct the type, quantity, and frequency of their substance use over the course of their lives. However, some data have shown that the level of detailed recall diminishes the further back a patient is asked to recall (Addict. Behav. 2010;35:1138-43).

The key is to assess to what degree the patient has insight into the nature of his or her level of substance use, said Dr. Greenfield, also a professor of psychiatry at Harvard Medical School in Boston.

Other components that should be included in the assessment include full psychiatric, medical, family, and social and developmental histories, such as the person’s age at first use; consequences associated with the substance use; and a determination of whether the person already has had treatment for substance use. Also, it is helpful to know if there have been any periods of abstinence and how those periods were maintained, as well as what factors trigger relapse.

“The age of a person’s first substance use serves as a framework,” said Dr. Greenfield, noting that use before the age of 14 years often is associated with preceding psychiatric disorders. Although co-occurring substance use and psychiatric disorders such as depression are more likely to have a worse prognosis, Dr. Greenfield said integrated treatment can enhance outcomes for both.

A useful screening and assessment tool Dr. Greenfield noted is the Addiction Severity Index, which evaluates how substance use might be affecting seven key areas of a person’s life such as their relationships and employment. The assessment is free and available from the National Institute on Alcohol Abuse and Alcoholism. Other helpful screens include the Clinical Institute Withdrawal Assessment for Alcohol, and the Clinical Opiate Withdrawal Scale, both of which are also free and available online.

Augmenting substance use assessments with other mental health status exams and appropriate biomarkers, such as serum testing, can help create a more solid picture of a patient’s overall health.

Dr. Greenfield has no disclosures or conflicts of interest. She has received support for her research on substance abuse in women from the National Institute on Drug Abuse.

[email protected]

On Twitter @whitneymcknight

TORONTO – All patients, regardless of presentation, should be screened for substance abuse, according to an expert, but barriers such as shame and fear often make an accurate assessment difficult.

“Using a warm, empathetic, nonjudgmental style can help,” Dr. Shelly F. Greenfield told an audience at this year’s American Psychiatric Association meeting.

More than 9% of the U.S. population aged 12 years or older use an illicit substance, including marijuana and opioids in the previous month, according to data from the 2013 National Survey on Drug Use and Health. Among the illicit drug users, more than 80% used marijuana. Nearly a quarter of people aged 12 or older were binge alcohol users, defined as having five or more alcoholic drinks on at least 1 day in the 30 days before the survey was conducted.

Early detection and intervention can help prevent more serious substance use issues that often co-occur with psychiatric comorbidities such as depression or anxiety, said Dr. Greenfield, an addiction psychiatrist with the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The overall goal, she said, is to “formulate the problem, educate the patient, and help him or her initiate appropriate interventions and treatment.”

Physicians should understand that there are very real barriers for many patients who may be unwilling to endorse signs of any substance use. “Some could have legal concerns, such as how revealing any information could impact child custody, for example,” Dr. Greenfield said. Often, patients will deny, minimize, or rationalize their use. Using open-ended interviewing techniques, such as those used in motivational interviewing, can help the clinician see how the patient is defining the problem. Questions that allow patients to frame actions in their own words can help avoid confrontation, reduce ambivalence, and prompt patients to consider a rationale for changing their behavior (Patient Educ. Couns. 2013;93:157-68).

For example, physicians could use a prompt such as, “I wonder if you could tell me about your pattern of use of alcohol in a typical week ...” This information could then be a starting point for discussing the patient’s drinking habits according to the Timeline Followback Method, where patients reconstruct the type, quantity, and frequency of their substance use over the course of their lives. However, some data have shown that the level of detailed recall diminishes the further back a patient is asked to recall (Addict. Behav. 2010;35:1138-43).

The key is to assess to what degree the patient has insight into the nature of his or her level of substance use, said Dr. Greenfield, also a professor of psychiatry at Harvard Medical School in Boston.

Other components that should be included in the assessment include full psychiatric, medical, family, and social and developmental histories, such as the person’s age at first use; consequences associated with the substance use; and a determination of whether the person already has had treatment for substance use. Also, it is helpful to know if there have been any periods of abstinence and how those periods were maintained, as well as what factors trigger relapse.

“The age of a person’s first substance use serves as a framework,” said Dr. Greenfield, noting that use before the age of 14 years often is associated with preceding psychiatric disorders. Although co-occurring substance use and psychiatric disorders such as depression are more likely to have a worse prognosis, Dr. Greenfield said integrated treatment can enhance outcomes for both.

A useful screening and assessment tool Dr. Greenfield noted is the Addiction Severity Index, which evaluates how substance use might be affecting seven key areas of a person’s life such as their relationships and employment. The assessment is free and available from the National Institute on Alcohol Abuse and Alcoholism. Other helpful screens include the Clinical Institute Withdrawal Assessment for Alcohol, and the Clinical Opiate Withdrawal Scale, both of which are also free and available online.

Augmenting substance use assessments with other mental health status exams and appropriate biomarkers, such as serum testing, can help create a more solid picture of a patient’s overall health.

Dr. Greenfield has no disclosures or conflicts of interest. She has received support for her research on substance abuse in women from the National Institute on Drug Abuse.

[email protected]

On Twitter @whitneymcknight

TORONTO – All patients, regardless of presentation, should be screened for substance abuse, according to an expert, but barriers such as shame and fear often make an accurate assessment difficult.

“Using a warm, empathetic, nonjudgmental style can help,” Dr. Shelly F. Greenfield told an audience at this year’s American Psychiatric Association meeting.

More than 9% of the U.S. population aged 12 years or older use an illicit substance, including marijuana and opioids in the previous month, according to data from the 2013 National Survey on Drug Use and Health. Among the illicit drug users, more than 80% used marijuana. Nearly a quarter of people aged 12 or older were binge alcohol users, defined as having five or more alcoholic drinks on at least 1 day in the 30 days before the survey was conducted.

Early detection and intervention can help prevent more serious substance use issues that often co-occur with psychiatric comorbidities such as depression or anxiety, said Dr. Greenfield, an addiction psychiatrist with the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The overall goal, she said, is to “formulate the problem, educate the patient, and help him or her initiate appropriate interventions and treatment.”

Physicians should understand that there are very real barriers for many patients who may be unwilling to endorse signs of any substance use. “Some could have legal concerns, such as how revealing any information could impact child custody, for example,” Dr. Greenfield said. Often, patients will deny, minimize, or rationalize their use. Using open-ended interviewing techniques, such as those used in motivational interviewing, can help the clinician see how the patient is defining the problem. Questions that allow patients to frame actions in their own words can help avoid confrontation, reduce ambivalence, and prompt patients to consider a rationale for changing their behavior (Patient Educ. Couns. 2013;93:157-68).

For example, physicians could use a prompt such as, “I wonder if you could tell me about your pattern of use of alcohol in a typical week ...” This information could then be a starting point for discussing the patient’s drinking habits according to the Timeline Followback Method, where patients reconstruct the type, quantity, and frequency of their substance use over the course of their lives. However, some data have shown that the level of detailed recall diminishes the further back a patient is asked to recall (Addict. Behav. 2010;35:1138-43).

The key is to assess to what degree the patient has insight into the nature of his or her level of substance use, said Dr. Greenfield, also a professor of psychiatry at Harvard Medical School in Boston.

Other components that should be included in the assessment include full psychiatric, medical, family, and social and developmental histories, such as the person’s age at first use; consequences associated with the substance use; and a determination of whether the person already has had treatment for substance use. Also, it is helpful to know if there have been any periods of abstinence and how those periods were maintained, as well as what factors trigger relapse.

“The age of a person’s first substance use serves as a framework,” said Dr. Greenfield, noting that use before the age of 14 years often is associated with preceding psychiatric disorders. Although co-occurring substance use and psychiatric disorders such as depression are more likely to have a worse prognosis, Dr. Greenfield said integrated treatment can enhance outcomes for both.

A useful screening and assessment tool Dr. Greenfield noted is the Addiction Severity Index, which evaluates how substance use might be affecting seven key areas of a person’s life such as their relationships and employment. The assessment is free and available from the National Institute on Alcohol Abuse and Alcoholism. Other helpful screens include the Clinical Institute Withdrawal Assessment for Alcohol, and the Clinical Opiate Withdrawal Scale, both of which are also free and available online.

Augmenting substance use assessments with other mental health status exams and appropriate biomarkers, such as serum testing, can help create a more solid picture of a patient’s overall health.

Dr. Greenfield has no disclosures or conflicts of interest. She has received support for her research on substance abuse in women from the National Institute on Drug Abuse.

[email protected]

On Twitter @whitneymcknight

TORONTO – Communities that emphasize early behavioral and mental health prevention and employ the resources to make early treatment and intervention possible see greatly improved mental health outcomes, according to Dr. Brian O’Donoghue, a speaker at the annual meeting of the American Psychiatric Association.

“With early psychosis, when it is treated intensively and holistically, the outcomes can be much more positive for young people who are experiencing a first-episode psychosis,” Dr. O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne, said in a video interview. Also discussed are how to create, develop, and run community health clinics for young people aged 15-24 years who are experiencing some form of psychosis.

[email protected]

On Twitter @whitneymcknight

TORONTO – Communities that emphasize early behavioral and mental health prevention and employ the resources to make early treatment and intervention possible see greatly improved mental health outcomes, according to Dr. Brian O’Donoghue, a speaker at the annual meeting of the American Psychiatric Association.

“With early psychosis, when it is treated intensively and holistically, the outcomes can be much more positive for young people who are experiencing a first-episode psychosis,” Dr. O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne, said in a video interview. Also discussed are how to create, develop, and run community health clinics for young people aged 15-24 years who are experiencing some form of psychosis.

[email protected]

On Twitter @whitneymcknight

TORONTO – Communities that emphasize early behavioral and mental health prevention and employ the resources to make early treatment and intervention possible see greatly improved mental health outcomes, according to Dr. Brian O’Donoghue, a speaker at the annual meeting of the American Psychiatric Association.

“With early psychosis, when it is treated intensively and holistically, the outcomes can be much more positive for young people who are experiencing a first-episode psychosis,” Dr. O’Donoghue, a clinical research fellow with Orygen, The National Centre of Excellence in Youth Mental Health near Melbourne, said in a video interview. Also discussed are how to create, develop, and run community health clinics for young people aged 15-24 years who are experiencing some form of psychosis.

[email protected]

On Twitter @whitneymcknight

TORONTO – Managing a diagnosis along the schizophrenia spectrum can be difficult not only for the patient, but also for the patient’s friends and loved ones. “It’s also hard on the clinician,” says Dr. Ira D. Glick, a professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University and a presenter at the annual American Psychiatric Association meeting. In this video, Dr. Glick outlines strategies for making life with schizophrenia less disruptive and even rewarding.

[email protected]

On Twitter @whitneymcknight

TORONTO – Managing a diagnosis along the schizophrenia spectrum can be difficult not only for the patient, but also for the patient’s friends and loved ones. “It’s also hard on the clinician,” says Dr. Ira D. Glick, a professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University and a presenter at the annual American Psychiatric Association meeting. In this video, Dr. Glick outlines strategies for making life with schizophrenia less disruptive and even rewarding.

[email protected]

On Twitter @whitneymcknight

TORONTO – Managing a diagnosis along the schizophrenia spectrum can be difficult not only for the patient, but also for the patient’s friends and loved ones. “It’s also hard on the clinician,” says Dr. Ira D. Glick, a professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University and a presenter at the annual American Psychiatric Association meeting. In this video, Dr. Glick outlines strategies for making life with schizophrenia less disruptive and even rewarding.

[email protected]

On Twitter @whitneymcknight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – Five in the afternoon, after a full day of cramming one’s brain with information from multiple sessions at an annual medical meeting, is a cruel time to offer a panel discussion linking behavioral economics, Freud, and the RDoC to future treatments for mental disorders.

But, at this year’s annual American Psychiatric Association meeting, that hour found me seated in a discussion of these things and more. The Evolution of Mathematical Psychiatry: Implications for Bridging DSM-5 and Research Domain Criteria Using Behavioral Game Theory simultaneously knocked me out and brought me to my senses. Psychiatry sure is getting exciting.

After the slightly bumptious way the release of the RDoC was announced in 2013, just days before the APA’s annual meeting and the official release of the DSM-5, it’s noteworthy to see how quickly the RDoC, which is now the primary mechanism for evaluating funding at the National Institute of Mental Health, is being embraced by at least some in psychiatry.

Unlike the DSM-5, which relies on “consensus definitions” of disease, as NIMH Director Thomas Insel put it in his stinging rebuke of the APA’s signature publication, the RDoC’s emphasis is on the creation of diagnostic tools from matrices of genetics, imaging, cognitive science, and neurobiology, among other fields.

“The beauty of the RDoC is that it allows us to integrate smaller theories, such as those from Freud and math, into a larger one,” the session’s discussant, Dr. Andrew Gerber, director of the New York State Psychiatric Institute’s MRI research program, New York, told the audience.

Not everyone is happy about this change in grant making for a variety of reasons, which I would summarize in general as dismay over the amount of effort and resources it can take to not do things the way they’ve always been done. However, some researchers I have spoken with who acknowledge the spirit of the RDoC, are concerned the criteria are still too narrow, overemphasizing the brain as the master organ that controls the entire body, rather than seeing it as simply an equal player in a bidirectional highway of signaling that can originate in the gut or the immune system, for example. Indeed, such literature is growing, with Dr. Charles Raison as one of its more prominent thought leaders.

Regardless of the RDoC’s possible limitations, its effect on psychiatry could prove revolutionary. The use of “decision science” to assess anomalies in cognitive function, which is one of the domains included in the RDoC, is evidence of this.

Decision science is the exploration of the nonconscious and the conscious processes, including implicit memory, procedural memory, and even habits involved when a person makes a decision to engage in a specific behavior. There is great potential for patients to be empowered by this, since it allows them to see their condition in terms of choice rather than affliction.

Here’s what that could mean for treating people with obsessive-compulsive disorder, for example. Instead of patients not having control over their compulsions, patients are quite literally just playing a game, one that involves two players: the patient and the patient’s future self. The object of the game, according to presenter Dr. Lawrence Amsel, who directs dissemination research for trauma services at the New York State Psychiatric Institute, is for the player in the present (the patient) to avoid blame when a calamity such as the house burning down is discovered by the patient’s future self.

Since the patient living in the present cannot control whether his house actually burns down, but he can prove that he was clever enough to check 14 times that the gas was not left on, he can legitimately claim, “this horrible thing had nothing to do with me.”

This point of view employs behavioral game theory, which economists use to predict irrationalities in consumer behavior. According to Dr. Amsel, it also can be applied to understanding the physiology of the mind: “Often, when people deviate from rational behavior, there is a way to understand that.”

What is the irrationality that causes a person to repeatedly check that he has turned off the stove? What is the reason he cannot cognitively process his multiple verifications that he in fact turned the stove off? It is simply that the patient with OCD finds less value in the present moment and plenty in the future, specifically, “the future me that is in the petty, angry mode,” said Dr. Amsel.

Is this a fear of having a negative impact on one’s future, of being unable to control the outcome, and thus control what others (in this case, one’s future self) think? Such are the sorts of questions Freud or Jung might have asked 100 years ago.

In today’s mathematical terms, Dr. Amsel explained it as an equation where the expected change in risk, multiplied by the potential disaster, is greater than the cost of the behavior, or in this case, constantly checking the stove. Psychiatry can leverage this scientific equation to help patients dispense with magical thinking and to see they have control over their actions, but not the outcomes.

According to Dr. Gerber, however, Freudian psychoanalysis still is implicit in decision science, because rather than just identifying and treating symptoms, as Freud accused clinical psychiatry of doing, it helps uncover the meaning inherent in a person’s behavior and the behavior’s relevance to the patient’s direct experience, just as Freud implored his disciples to do.

“Symptoms are rational,” Dr. Gerber said.

Symptoms are the representation of what Dr. Gerber referred to as the “schema, a construct that serves as a psychological intermediary between lower-level physiologic or cognitive process, such as long-term memory or affective state, and response such as thoughts, feelings, and behavior, to a complex stimulus.”

In other words, what does obsessively checking the stove actually mean to the person?

By using math to untether psychiatry from methodical, clinical thinking and cast it slightly adrift into a nonlinear sea seems to me an epic moment in the history of the field. Rather than rely solely on a didactic DSM-5 rife with soulless jargon and acronyms such as OCD, PTSD, TBI, and ADHD, patients are reintroduced to themselves through the poetry of their own metaphors of being. This empowers them to use words and images to bridge their conscious mind to what Dr. Gerber and his copanelists referred to as the nonconscious mind (deftly differentiating it from Freud’s and Jung’s unconscious mind).

During the question and answer period, several in the audience expressed their concern that such leaping science will outpace policy and practice (I wager it will). The response from the panel was in a sense to “use your words” and to help patients contextualize their nonconscious decisions with metaphor, which the speakers pointed out can be done in practice now, without waiting for studies or policy changes, although Dr. Amsel and Dr. Gerber both noted that functional MRI studies of what happens neurobiologically in the minds of people with OCD intended to support this type of decision science are underway.

Meanwhile, a metaphor-inspired intervention in the case of the patient with OCD, according to Dr. Amsel, who specifically stressed the power of metaphors to make a situation more real to a patient, is to suggest becoming more aware (conscious) of the various constituencies “running” the patient’s cognitive processes: “Your life is being run by a committee, but you’re not invited. So we at least need to get you an invitation.”

After the session, I spoke with Dr. Gerber. We agreed there is a place for the DSM-5, what Dr. Insel referred to as, “a reliable dictionary” that helps clinicians all speak the same language. Yet, I am intrigued by how the RDoC seems to breathe life into that dictionary by inspiring these connections between the conscious and the nonconscious in cognition.

With the return of such beauty and wit to the language of the mind, I am also intrigued to consider how the RDoC might also inspire a true renaissance of the medical arts. I have often considered psychiatry not a field so much as a vast and deep sea with math and science along one shore and arts and literature on another. It is on the science shore where mental disorders are neatly contained by the nosology of the DSM-5, while on the arts and literature shore are the howls of human experience depicted in the words and pictures of those who’ve sought to give meaning to their individual experiences with the mental pain and anguish listed on the other shore.

I often have lamented the senseless distance between these shores. We need a bridge between the two, a place to stand and gaze at our reflections in the water, and a sturdy way to cross over. Could the RDoC be the bridge between having a way to define and treat, and having a way to talk ourselves out of the horror of a purely random existence?

“It’s a shame the way the RDoC has been perceived by some,” Dr. Gerber told me. “There’s a lot of good in it.”

Or, as Joyce wrote in Ulysses, “I go to encounter for the millionth time the reality of experience and to forge in the smithy of my soul the uncreated conscience of my race.”

[email protected]

On Twitter @whitneymcknight

TORONTO – Whether they had relapsed in the first 2 weeks strongly predicted a successful long-term outcome in patients with prescription opioid dependence undergoing treatment with buprenorphine-naloxone, according to findings presented at the annual meeting of the American Psychiatric Association.

“People either need to hit the ground running and do well quickly, or you need to cage something within a couple of weeks,” said Dr. Roger D. Weiss, chief of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The typical time course of response to buprenorphine-naloxone in the treatment of prescription opioid dependence is not known, and given the overall studies’ fairly poor success rate (<10% at completion), knowing this information could help guide clinical practice in the treatment of this population, Dr. Weiss said.

Most studies of buprenorphine have focused on heroin users, who differ from prescription opioid users on socioeconomic and compliance measures.

The researchers looked at both positive predictive value – the degree to which initial opioid abstinence predicted final successful outcome at the end of 12 weeks, along with negative predictive value – the degree to which initial opioid use predicted final unsuccessful outcome.

“So, does getting off to a good start predict a good outcome and does getting off to a bad start predict a bad outcome?” Dr. Weiss asked.

Turns out, that if people were abstinent in week 1, the likelihood they would be absent at weeks 9-12 was 49%, “essentially a coin flip,” he said. If abstinence were maintained for the first 2 weeks, the PPV went up to 56%, rising a few more points out to week 4.

“Two weeks gave you as good a prediction as you’re going to get, but it’s not a great prediction,” explained Dr. Weiss, also a professor of psychiatry at Harvard Medical School in Boston.

However, looking at the negative predictive value offered more information. If the patients used opioids in week 1, the likelihood of a bad outcome was 80%, and this rose to 94% if they used in the first 2 weeks and 97% if they used in the first 4 weeks.

“So if they don’t do well in 2 weeks, the likelihood that, if you just wait a little while, they’ll do better, was almost nil,” Dr. Weiss said.

The Prescription Opioid Addiction Treatment Study (POATS) compared treatments for prescription opioid dependence, using buprenorphine-naloxone of different durations and counseling of varying intensities. The trial was conducted as part of the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) at 10 participating sites across the United States.

With 653 patients, POATS was the largest study ever conducted for prescription opioid dependence and sought to determine the value of added drug counseling to buprenorphine-naloxone treatment, and determine the optimal length of buprenorphine-naloxone treatment for these particular patients. To be eligible for enrollment, patients had to have a DSM-IV diagnosis of opioid dependence, not just physical dependence.

In POATS, patients began with 1-2 weeks of buprenorphine-naloxone treatment followed by a 4-week taper and were then randomly assigned to regular or more intensive drug counseling.

Patients who had a successful outcome in phase 1 (defined as 4 days or fewer of use per month, no positive urine screens for 2 consecutive weeks, no injection of opioids, no other formal substance abuse treatment, and not more than one missing urine sample) were considered finished with the study.

Those who relapsed had the option of going to phase 2, where they received 3 months of buprenorphine-naloxone stabilization and were rerandomized to standard care or standard care plus extra drug counseling. They also received 12 weeks of buprenorphine-naloxone treatment, followed by a taper period until week 16.

Dr. Weiss disclosed that he has consulted to Reckitt Benckiser Pharmaceuticals, maker of the drug, but vowed to “present the content in a fair and balanced manner.”

TORONTO – Whether they had relapsed in the first 2 weeks strongly predicted a successful long-term outcome in patients with prescription opioid dependence undergoing treatment with buprenorphine-naloxone, according to findings presented at the annual meeting of the American Psychiatric Association.

“People either need to hit the ground running and do well quickly, or you need to cage something within a couple of weeks,” said Dr. Roger D. Weiss, chief of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The typical time course of response to buprenorphine-naloxone in the treatment of prescription opioid dependence is not known, and given the overall studies’ fairly poor success rate (<10% at completion), knowing this information could help guide clinical practice in the treatment of this population, Dr. Weiss said.

Most studies of buprenorphine have focused on heroin users, who differ from prescription opioid users on socioeconomic and compliance measures.

The researchers looked at both positive predictive value – the degree to which initial opioid abstinence predicted final successful outcome at the end of 12 weeks, along with negative predictive value – the degree to which initial opioid use predicted final unsuccessful outcome.

“So, does getting off to a good start predict a good outcome and does getting off to a bad start predict a bad outcome?” Dr. Weiss asked.

Turns out, that if people were abstinent in week 1, the likelihood they would be absent at weeks 9-12 was 49%, “essentially a coin flip,” he said. If abstinence were maintained for the first 2 weeks, the PPV went up to 56%, rising a few more points out to week 4.

“Two weeks gave you as good a prediction as you’re going to get, but it’s not a great prediction,” explained Dr. Weiss, also a professor of psychiatry at Harvard Medical School in Boston.

However, looking at the negative predictive value offered more information. If the patients used opioids in week 1, the likelihood of a bad outcome was 80%, and this rose to 94% if they used in the first 2 weeks and 97% if they used in the first 4 weeks.

“So if they don’t do well in 2 weeks, the likelihood that, if you just wait a little while, they’ll do better, was almost nil,” Dr. Weiss said.

The Prescription Opioid Addiction Treatment Study (POATS) compared treatments for prescription opioid dependence, using buprenorphine-naloxone of different durations and counseling of varying intensities. The trial was conducted as part of the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) at 10 participating sites across the United States.

With 653 patients, POATS was the largest study ever conducted for prescription opioid dependence and sought to determine the value of added drug counseling to buprenorphine-naloxone treatment, and determine the optimal length of buprenorphine-naloxone treatment for these particular patients. To be eligible for enrollment, patients had to have a DSM-IV diagnosis of opioid dependence, not just physical dependence.

In POATS, patients began with 1-2 weeks of buprenorphine-naloxone treatment followed by a 4-week taper and were then randomly assigned to regular or more intensive drug counseling.

Patients who had a successful outcome in phase 1 (defined as 4 days or fewer of use per month, no positive urine screens for 2 consecutive weeks, no injection of opioids, no other formal substance abuse treatment, and not more than one missing urine sample) were considered finished with the study.

Those who relapsed had the option of going to phase 2, where they received 3 months of buprenorphine-naloxone stabilization and were rerandomized to standard care or standard care plus extra drug counseling. They also received 12 weeks of buprenorphine-naloxone treatment, followed by a taper period until week 16.

Dr. Weiss disclosed that he has consulted to Reckitt Benckiser Pharmaceuticals, maker of the drug, but vowed to “present the content in a fair and balanced manner.”

TORONTO – Whether they had relapsed in the first 2 weeks strongly predicted a successful long-term outcome in patients with prescription opioid dependence undergoing treatment with buprenorphine-naloxone, according to findings presented at the annual meeting of the American Psychiatric Association.

“People either need to hit the ground running and do well quickly, or you need to cage something within a couple of weeks,” said Dr. Roger D. Weiss, chief of the division of alcohol and drug abuse at McLean Hospital in Belmont, Mass. The typical time course of response to buprenorphine-naloxone in the treatment of prescription opioid dependence is not known, and given the overall studies’ fairly poor success rate (<10% at completion), knowing this information could help guide clinical practice in the treatment of this population, Dr. Weiss said.

Most studies of buprenorphine have focused on heroin users, who differ from prescription opioid users on socioeconomic and compliance measures.

The researchers looked at both positive predictive value – the degree to which initial opioid abstinence predicted final successful outcome at the end of 12 weeks, along with negative predictive value – the degree to which initial opioid use predicted final unsuccessful outcome.

“So, does getting off to a good start predict a good outcome and does getting off to a bad start predict a bad outcome?” Dr. Weiss asked.

Turns out, that if people were abstinent in week 1, the likelihood they would be absent at weeks 9-12 was 49%, “essentially a coin flip,” he said. If abstinence were maintained for the first 2 weeks, the PPV went up to 56%, rising a few more points out to week 4.

“Two weeks gave you as good a prediction as you’re going to get, but it’s not a great prediction,” explained Dr. Weiss, also a professor of psychiatry at Harvard Medical School in Boston.

However, looking at the negative predictive value offered more information. If the patients used opioids in week 1, the likelihood of a bad outcome was 80%, and this rose to 94% if they used in the first 2 weeks and 97% if they used in the first 4 weeks.

“So if they don’t do well in 2 weeks, the likelihood that, if you just wait a little while, they’ll do better, was almost nil,” Dr. Weiss said.

The Prescription Opioid Addiction Treatment Study (POATS) compared treatments for prescription opioid dependence, using buprenorphine-naloxone of different durations and counseling of varying intensities. The trial was conducted as part of the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) at 10 participating sites across the United States.

With 653 patients, POATS was the largest study ever conducted for prescription opioid dependence and sought to determine the value of added drug counseling to buprenorphine-naloxone treatment, and determine the optimal length of buprenorphine-naloxone treatment for these particular patients. To be eligible for enrollment, patients had to have a DSM-IV diagnosis of opioid dependence, not just physical dependence.

In POATS, patients began with 1-2 weeks of buprenorphine-naloxone treatment followed by a 4-week taper and were then randomly assigned to regular or more intensive drug counseling.

Patients who had a successful outcome in phase 1 (defined as 4 days or fewer of use per month, no positive urine screens for 2 consecutive weeks, no injection of opioids, no other formal substance abuse treatment, and not more than one missing urine sample) were considered finished with the study.

Those who relapsed had the option of going to phase 2, where they received 3 months of buprenorphine-naloxone stabilization and were rerandomized to standard care or standard care plus extra drug counseling. They also received 12 weeks of buprenorphine-naloxone treatment, followed by a taper period until week 16.

Dr. Weiss disclosed that he has consulted to Reckitt Benckiser Pharmaceuticals, maker of the drug, but vowed to “present the content in a fair and balanced manner.”

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

[email protected]


On Twitter @whitneymcknight

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

[email protected]


On Twitter @whitneymcknight

TORONTO – The American Psychiatric Association’s consumer guide to the DSM-5, “Understanding Mental Disorders,” debuted at the organization’s annual meeting this year.

Compared with the pricey clinical version of the manual, you get a lot for your $24.95 ($22.21 with an Amazon Prime account). At 370 pages, the guide is an easily digestible compendium; the diagnoses are grouped as they are in the primary manual, although without specifiers or subsets. Instead, there are bulleted lists of risk factors and symptoms. Treatment options are also bulleted, as are tips for remaining compliant with treatment regimens.

There are case histories written in lay person language and even blurbs that offer encouragement to those who might be, however slightly, alarmed to learn about various illnesses described. For example, in the chapter about “disorders that start in childhood” (neurodevelopmental disorders), the reader is advised that “treatment can lead to learning new ways to manage symptoms … and it can also offer hope.”

Although it’s the first book written and published by the APA specifically for the general public, when I asked the guide’s editorial adviser, Dr. Jeffrey Borenstein, if primary care doctors, who are very often the ones on the front lines of diagnosing and treating mental illness, would also benefit from having a copy at hand, he said yes. But primary care physicians apparently were not foremost in the minds of the editorial board that compiled this guide and planned its utility.

According to Dr. Borenstein, the guide is intended for the general public. In an interview, however, he singled out in particular, teachers, clergy, and others whose job it is to serve the community at large.

Now that the Medicare Access and CHIP Reauthorization Act means our health care system is moving inexorably toward value-based care and that physicians risk losing money if their overall patient panel outcomes – including mental health – are poor, understanding how to diagnose and appropriately treat mental and behavioral health issues is of growing concern, particularly in primary care.

Earlier this year, I spoke with Chet Burrell, CEO of CareFirst, the Patient-Centered Medical Home division of BlueCross BlueShield. He told me that since 1 in 10 hospital admissions out of the 10,000 admissions CareFirst covers annually are behavioral health and substance abuse related, not only does that mean primary care practices are coordinating complex, postdischarge psychiatric care on as much as 10% of their patient panels, it also means that these patients have been left untreated or undertreated long enough for their illnesses to lead to an acute crisis, which is costly in one way or another to the patient, the payer, and the physician practice. “To get admitted [to the hospital] for a behavioral health or substance abuse issue, you have to be pretty sick,” Mr. Burrell said.

By connecting primary care physicians with psychiatrists in the community, however, as well as adding other structural support such as social workers or nurse practitioners, Mr. Burrell said primary care physicians in his network were beginning to see better outcomes and less financial risk.

It’s not that the APA is unaware of the growing need in the primary care realm for psychiatric expertise: At its annual meeting, the APA held a session entitled, “Educating Psychiatrists for Work in Integrated Care: Focus on Interdisciplinary Collaboration.” (I attended and tweeted pearls from each speaker @whitneymcknight if you’d like to see highlights). While attending the session, I detected two salient themes across the four presentations and concluding panel discussion. The first was that for all the increased mental and behavioral health training various medical school programs have added in the last decade, newly graduated primary care physicians are still underprepared for the amount of mental health concerns with which they will be faced in practice. The second was that psychiatrists and primary care physicians don’t know how to talk to one another effectively; one reason is that primary care physicians often feel that psychiatrists patronize them.

Psychiatrists can’t necessarily do much about the former, at least not in short order, but they can certainly do something about the latter, particularly in light of the APA’s new, forward-thinking branding campaign: “medical leadership for mind, brain, and body.”

Even if psychiatrists, whom many in other specialties “forget” are actually medical doctors, now want to claim their place at the health care table in an era when the bidirectional nature of mental and physical health is increasingly substantiated in myriad studies and is emphasized in ever more health policy–related decisions, the fact is that, at least where nonserious mental illness is concerned, the gatekeepers of access to mental health in this country are not psychiatrists but primary care doctors. As we move toward a value-based accountable care system where mental health outcomes can mean the difference between a physician receiving an upgrade or a downgrade, the demand for psychiatrists and other mental health professionals who can help ensure good, efficient patient outcomes will only expand.

Which returns us to the lay person’s guide to the DSM-5: It’s well organized. It’s easy to understand. And while it is in hard copy only, it’s handy for primary care physicians who often use the same search criteria as their patients might when turning to Dr. Google to find a quick answer to something with which they are not that familiar. It’s a pretty good bridge between primary care and psychiatry.

Dr. Borenstein had no relevant financial disclosures. He is the editor-in-chief of the APA’s Psychiatric News.

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