Medical Education Library

A Best Practices Supplement to Pediatric News^®. This supplement was sponsored by Perrigo Nutritionals.

Topics

• Introduction
• Store Brands and Advertised Brands
• FDA Regulation of Formula
• Formula Selection
• The Problem of Infant Formula Dilution
• Is Switching Formula Safe?
• Conclusion

Faculty/Faculty Disclosure

Joel R. Rosh, MD
Director, Pediatric
Gastroenterology
Goryeb Children’s
Hospital/Atlantic Health
Morristown, NJ
Professor of Pediatrics
Icahn School of Medicine
at Mount Sinai
New York, NY

Dr. Rosh discloses that he is on an advisory board for Perrigo Nutritionals.

Medical Education Library

A Best Practices Supplement to Pediatric News^®. This supplement was sponsored by Perrigo Nutritionals.

Topics

• Introduction
• Store Brands and Advertised Brands
• FDA Regulation of Formula
• Formula Selection
• The Problem of Infant Formula Dilution
• Is Switching Formula Safe?
• Conclusion

Faculty/Faculty Disclosure

Joel R. Rosh, MD
Director, Pediatric
Gastroenterology
Goryeb Children’s
Hospital/Atlantic Health
Morristown, NJ
Professor of Pediatrics
Icahn School of Medicine
at Mount Sinai
New York, NY

Dr. Rosh discloses that he is on an advisory board for Perrigo Nutritionals.

Medical Education Library

A Best Practices Supplement to Pediatric News^®. This supplement was sponsored by Perrigo Nutritionals.

Topics

• Introduction
• Store Brands and Advertised Brands
• FDA Regulation of Formula
• Formula Selection
• The Problem of Infant Formula Dilution
• Is Switching Formula Safe?
• Conclusion

Faculty/Faculty Disclosure

Joel R. Rosh, MD
Director, Pediatric
Gastroenterology
Goryeb Children’s
Hospital/Atlantic Health
Morristown, NJ
Professor of Pediatrics
Icahn School of Medicine
at Mount Sinai
New York, NY

Dr. Rosh discloses that he is on an advisory board for Perrigo Nutritionals.

In the late-20th century, family therapy was a new therapeutic modality. It was an exciting time! Family therapy and the application of systems principles to families was considered “thinking outside the box.” Different schools of family therapy were developed, usually based in an academic center and led by a charismatic leader, often a psychiatrist.

Today, with the rise in the popularity of psychopharmacology and the promise of biological interventions, there are fewer opportunities for family systems training within psychiatric residency programs. In order to receive family systems training, a psychiatrist may decide to enroll in an independent family training institute, such as the Ackerman Institute for the Family in New York. However, there are still some psychiatric residency programs that consider learning to work with families to be an essential psychotherapeutic skill.

Psychiatric training in family therapy

Dr. Ellen Berman, president of the Association of Family Psychiatrists, recently asked family psychiatrists to indicate psychiatric residency programs offering family systems training. Nine programs were identified. Here is a description of each program and contact information:

•  Albert Einstein College of Medicine, New York

“We have a well-established and extensive Family Studies program that is part of the department of psychiatry at Albert Einstein College of Medicine and is well integrated into the residency training program. All residents in the 4 years of the training program at Montefiore Medical Center and Bronx (N.Y.) Psychiatric Center as well as child fellows receive supervision in couples and family therapy, courses, seminars, electives, and more. Faculty and residents have presented different innovative projects related to family and systems at national conferences and have written papers on their clinical work.”

– Contact: [email protected], Director of Family Studies, department of psychiatry, Albert Einstein College of Medicine.

•  McGill University, Montreal

“We have a very active family therapy community in Montreal, with [Dr.] Herta Guttman as our pioneer. At the Jewish General [Hospital] department of psychiatry, we run an [American Association for Marriage and Family Therapy]–accredited postgraduate certificate couple and family therapy program. This program primarily trains community mental health practitioners (social workers, psychologists, etc.), however, we have had psychiatrists take this course. This year, we are training our first Couple and Family Fellow (child psychiatrist) through the department of psychiatry.

In McGill Psychiatry, we have a new family skills teaching module in the McGill Resident Diploma Program. We will provide 3 hours of teaching in the R1 year (basic concepts). In the R2 and R3 years, residents receive training on a range of family therapy topics. The curriculum was inspired by the Group for the Advancement of Psychiatry curriculum. Dr. Nick Casacalenda spearheaded this initiative. There are 3 hours of family teaching in the diploma course module: gender, social, and cultural aspects of psychiatry, and 6 hours in the child psychiatry module.”

– Contact: Sharon Bond, Ph.D.; School of Social Work; Director, Couple and Family Therapy Program.

•  NYU School of Medicine

“I am the director of service at the Roberto Clemente Center in the Lower East Side (now East Village) in Manhattan. The center is part of the departments of mental health of both Gouverneur [Healthcare Services] and Bellevue. We have an academic affiliation with New York University School of Medicine. The center was started about 30 years ago by a psychologist, Jaime Inclan, Ph.D. He was initially was trained by [Dr.] Salvador Minuchin. As a family clinic embedded in the community, we mostly serve minority underserved populations. We provide primary health and mental health services. We have been providing for decades training to medical students, psychology interns, and social work students.”

– Contact: Dr. Miguel Vilaro-Colon, Clinical Assistant Professor of Psychiatry, NYU School of Medicine.

•  Stanford (Calif.) University

“Our 4-year training program in couples and family therapy begins with didactics and family meetings (inpatient) in the first year; didactics and opportunities for a couples and family therapy clinical elective as [postgraduate year]-2s; live case observation in the family therapy program at the [Veterans Affairs] Palo Alto Health Care System, as well as an intensive seminar at Stanford during the PGY-3 year, and supervised outpatient clinical work in Stanford’s Couples and Family Therapy Clinic during the PGY-3 and PGY-4 years. Residents who are interested in child and adolescent psychiatry can focus their PGY-3 rotation on family cases with a child/adolescent focus. An earlier version of this training sequence is described in program for residents is described in ‘A Model for Reintegrating Couples and Family Therapy Training in Psychiatric Residency Programs’ ” (Acad. Psychiatry 2008;32:81-6).

– Contact: Douglas S. Rait, Ph.D., Chief, Couples and Family Therapy Clinic, Clinical Professor of Psychiatry & Behavioral Sciences, Stanford University.

•  University of Pennsylvania Perlman School of Medicine

“The Center for Couples and Adult Families in the department of psychiatry includes a didactic program for residents spanning all 4 years and supervision in PGY-3 and 4. Residents help run multifamily psychoeducation groups in the bipolar clinic, and see couples and families in their outpatient clinics. Our focus is on family inclusion and family psychoeducation for all patients when possible, with couple and adult family therapy when appropriate. Our curriculum is on our website As the clinical director, I work closely with Ellen Berman, who founded the center 5 years ago.”

– Contact: Jacqueline Hudak, Ph.D., LMFT, Center for Couples and Adult Families, Department of Psychiatry, Perelman School of Medicine.

•  Mount Sinai Beth Israel, New York The Family Center for Bipolar provides services to patients with bipolar disorder “within the context of the family.” In addition, Dr. Igor Galynker, who runs the center, gives a series of lectures on family inclusion. The center also has a formal training program in family therapy run by Haya Mermelstein, CSW.

– Contact: Dr. Igor Galynker, professor of psychiatry, Icahn School of Medicine at Mount Sinai; director, the Family Center for Bipolar Disorder; Associate Chairman, Department Of Psychiatry and Behavioral Sciences.

•  Brown University, Providence, R.I.

“We have a formal Family Therapy Training Program in the department of psychiatry at Brown University, based at Rhode Island Hospital.”

– Contact: Dr. Gabor I. Keitner, Associate Chief of Psychiatry, Rhode Island and Miriam Hospitals; Professor, Department of Psychiatry, Brown University.

•  University of Rochester, Institute for the Family

“An emphasis on family is embedded in all of our training. The residents have a formal didactic curriculum and participate in family care and family research. Many of the residents fast track into a child fellowship, which has an extensive program in family therapy.

– Contact: Dr. [email protected], Director of Psychiatry Residency Education, University of Rochester Medical Center.

•  University of Colorado Denver

“Our department offers a unique psychotherapy scholar track. The mission of this track is to offer advanced psychotherapy training to a subgroup of psychiatric residents, within an adult general residency program, who wish to learn and do psychotherapy. Within this track we offer extensive family therapy training. The family therapy component consists of didactics and direct supervision. It runs through the 4 years of residency. There are several experienced family therapists on the faculty who supervise in this program.”

– Contact: Dr. [email protected], Vice Chair, Department of Psychiatry.

A multidisciplinary field

Family systems training occurs in other disciplines: psychology, social work, and marriage and family therapy (MFT) programs. The number of MFT programs across the United States is large, reflecting the demand for family systems therapists.

Psychologists with a special interest in family therapy belong to the American Psychological Association’s Division 43. Division 43 supports family-oriented clinical and scientific activities as well as education and public policy, a journal called the Journal of Family Psychology, and a quarterly newsletter called The Family Psychologist. Many psychologists are trained in family therapy work in primary care settings. The current president of American Psychological Association, Nadine J. Kaslow, Ph.D., is a family therapist who helps underserved and underprivileged populations receive culturally competent, evidence-based, biopsychosocially oriented mental health services.

Social Workers are required to take two exams: one to be “licensed” as an LCSW (licensed clinical social worker) after graduation with a master’s degree. After 3,000 hours of supervised clinical practice, social worker takes second exam for independent licensure LICSW (licensed independent clinical social worker).

Social work schools have a course or two in family therapy. After graduation, students may choose to specialize in couples and family therapy. Like psychiatric and psychological training programs, there is wide variation in the amount of family therapy taught in schools of social work.

Marriage and family therapists (MFTs) have their own organization, the American Association for Marriage and Family Therapy (AAMFT). This organization’s training is specific to families and couples. Members are required to be supervised in clinical practice for 2 years. AAMFT produces the Journal of Marital and Family Therapy. The AAMFT website also lists accredited programs in the United States and Canada.

Two American journals in this area are interdisciplinary: Family Process and Families, Systems & Health. Family Process has broad representation on its board from all disciplines and has a strong focus on family systems research and social justice. Family Process aims to support emerging researchers and clinicians worldwide, and periodically offers grants. Families, Systems & Health is multidisciplinary with a focus on research and clinical practice in medical illness, and health psychology.

The American Family Therapy Academy (AFTA) is the only organization that is interdisciplinary. Founded in 1977, AFTA’s objectives include “the advancement of theories, therapies, research, and professional education that regard the family as a unit in a social context, to make information about family therapy available to practitioners in other fields of knowledge and to the public and to foster collaboration among the medical, psychological, social, legal, and other professions that serve families and the science and practice of family therapy.”

AFTA is outspoken on issues that affect families. For example, its Immigration Position Statement addresses the negative impact of U.S. immigration policy on families and children. AFTA has strong views about the DSM-5, stating that “the current revision of the DSM continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines resulting in invalid diagnostic categories and treatment protocols. The DSM is dominant in determining mental health diagnosis and treatment and is more harmful than helpful in delineating best practices.” The next AFTA conference is in June 2015, and the theme is “Global Ecologies: Connections among Self, Families, Communities, and Cultures.”

Family therapy has grown from a small group of interested academics, mostly psychiatrists, to a large group of interdisciplinary professionals. Today, psychiatrists have less access to family systems training than in previous decades but can still access training. In addition to attending conferences, psychiatrists interested in this area might see whether training programs would accept them into their courses.

For those psychiatrists who have not had formal training during residency training, this review of programs is a good starting point for seeking family systems training.

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of the recently published book Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013).

In the late-20th century, family therapy was a new therapeutic modality. It was an exciting time! Family therapy and the application of systems principles to families was considered “thinking outside the box.” Different schools of family therapy were developed, usually based in an academic center and led by a charismatic leader, often a psychiatrist.

Today, with the rise in the popularity of psychopharmacology and the promise of biological interventions, there are fewer opportunities for family systems training within psychiatric residency programs. In order to receive family systems training, a psychiatrist may decide to enroll in an independent family training institute, such as the Ackerman Institute for the Family in New York. However, there are still some psychiatric residency programs that consider learning to work with families to be an essential psychotherapeutic skill.

Psychiatric training in family therapy

Dr. Ellen Berman, president of the Association of Family Psychiatrists, recently asked family psychiatrists to indicate psychiatric residency programs offering family systems training. Nine programs were identified. Here is a description of each program and contact information:

•  Albert Einstein College of Medicine, New York

“We have a well-established and extensive Family Studies program that is part of the department of psychiatry at Albert Einstein College of Medicine and is well integrated into the residency training program. All residents in the 4 years of the training program at Montefiore Medical Center and Bronx (N.Y.) Psychiatric Center as well as child fellows receive supervision in couples and family therapy, courses, seminars, electives, and more. Faculty and residents have presented different innovative projects related to family and systems at national conferences and have written papers on their clinical work.”

– Contact: [email protected], Director of Family Studies, department of psychiatry, Albert Einstein College of Medicine.

•  McGill University, Montreal

“We have a very active family therapy community in Montreal, with [Dr.] Herta Guttman as our pioneer. At the Jewish General [Hospital] department of psychiatry, we run an [American Association for Marriage and Family Therapy]–accredited postgraduate certificate couple and family therapy program. This program primarily trains community mental health practitioners (social workers, psychologists, etc.), however, we have had psychiatrists take this course. This year, we are training our first Couple and Family Fellow (child psychiatrist) through the department of psychiatry.

In McGill Psychiatry, we have a new family skills teaching module in the McGill Resident Diploma Program. We will provide 3 hours of teaching in the R1 year (basic concepts). In the R2 and R3 years, residents receive training on a range of family therapy topics. The curriculum was inspired by the Group for the Advancement of Psychiatry curriculum. Dr. Nick Casacalenda spearheaded this initiative. There are 3 hours of family teaching in the diploma course module: gender, social, and cultural aspects of psychiatry, and 6 hours in the child psychiatry module.”

– Contact: Sharon Bond, Ph.D.; School of Social Work; Director, Couple and Family Therapy Program.

•  NYU School of Medicine

“I am the director of service at the Roberto Clemente Center in the Lower East Side (now East Village) in Manhattan. The center is part of the departments of mental health of both Gouverneur [Healthcare Services] and Bellevue. We have an academic affiliation with New York University School of Medicine. The center was started about 30 years ago by a psychologist, Jaime Inclan, Ph.D. He was initially was trained by [Dr.] Salvador Minuchin. As a family clinic embedded in the community, we mostly serve minority underserved populations. We provide primary health and mental health services. We have been providing for decades training to medical students, psychology interns, and social work students.”

– Contact: Dr. Miguel Vilaro-Colon, Clinical Assistant Professor of Psychiatry, NYU School of Medicine.

•  Stanford (Calif.) University

“Our 4-year training program in couples and family therapy begins with didactics and family meetings (inpatient) in the first year; didactics and opportunities for a couples and family therapy clinical elective as [postgraduate year]-2s; live case observation in the family therapy program at the [Veterans Affairs] Palo Alto Health Care System, as well as an intensive seminar at Stanford during the PGY-3 year, and supervised outpatient clinical work in Stanford’s Couples and Family Therapy Clinic during the PGY-3 and PGY-4 years. Residents who are interested in child and adolescent psychiatry can focus their PGY-3 rotation on family cases with a child/adolescent focus. An earlier version of this training sequence is described in program for residents is described in ‘A Model for Reintegrating Couples and Family Therapy Training in Psychiatric Residency Programs’ ” (Acad. Psychiatry 2008;32:81-6).

– Contact: Douglas S. Rait, Ph.D., Chief, Couples and Family Therapy Clinic, Clinical Professor of Psychiatry & Behavioral Sciences, Stanford University.

•  University of Pennsylvania Perlman School of Medicine

“The Center for Couples and Adult Families in the department of psychiatry includes a didactic program for residents spanning all 4 years and supervision in PGY-3 and 4. Residents help run multifamily psychoeducation groups in the bipolar clinic, and see couples and families in their outpatient clinics. Our focus is on family inclusion and family psychoeducation for all patients when possible, with couple and adult family therapy when appropriate. Our curriculum is on our website As the clinical director, I work closely with Ellen Berman, who founded the center 5 years ago.”

– Contact: Jacqueline Hudak, Ph.D., LMFT, Center for Couples and Adult Families, Department of Psychiatry, Perelman School of Medicine.

•  Mount Sinai Beth Israel, New York The Family Center for Bipolar provides services to patients with bipolar disorder “within the context of the family.” In addition, Dr. Igor Galynker, who runs the center, gives a series of lectures on family inclusion. The center also has a formal training program in family therapy run by Haya Mermelstein, CSW.

– Contact: Dr. Igor Galynker, professor of psychiatry, Icahn School of Medicine at Mount Sinai; director, the Family Center for Bipolar Disorder; Associate Chairman, Department Of Psychiatry and Behavioral Sciences.

•  Brown University, Providence, R.I.

“We have a formal Family Therapy Training Program in the department of psychiatry at Brown University, based at Rhode Island Hospital.”

– Contact: Dr. Gabor I. Keitner, Associate Chief of Psychiatry, Rhode Island and Miriam Hospitals; Professor, Department of Psychiatry, Brown University.

•  University of Rochester, Institute for the Family

“An emphasis on family is embedded in all of our training. The residents have a formal didactic curriculum and participate in family care and family research. Many of the residents fast track into a child fellowship, which has an extensive program in family therapy.

– Contact: Dr. [email protected], Director of Psychiatry Residency Education, University of Rochester Medical Center.

•  University of Colorado Denver

“Our department offers a unique psychotherapy scholar track. The mission of this track is to offer advanced psychotherapy training to a subgroup of psychiatric residents, within an adult general residency program, who wish to learn and do psychotherapy. Within this track we offer extensive family therapy training. The family therapy component consists of didactics and direct supervision. It runs through the 4 years of residency. There are several experienced family therapists on the faculty who supervise in this program.”

– Contact: Dr. [email protected], Vice Chair, Department of Psychiatry.

A multidisciplinary field

Family systems training occurs in other disciplines: psychology, social work, and marriage and family therapy (MFT) programs. The number of MFT programs across the United States is large, reflecting the demand for family systems therapists.

Psychologists with a special interest in family therapy belong to the American Psychological Association’s Division 43. Division 43 supports family-oriented clinical and scientific activities as well as education and public policy, a journal called the Journal of Family Psychology, and a quarterly newsletter called The Family Psychologist. Many psychologists are trained in family therapy work in primary care settings. The current president of American Psychological Association, Nadine J. Kaslow, Ph.D., is a family therapist who helps underserved and underprivileged populations receive culturally competent, evidence-based, biopsychosocially oriented mental health services.

Social Workers are required to take two exams: one to be “licensed” as an LCSW (licensed clinical social worker) after graduation with a master’s degree. After 3,000 hours of supervised clinical practice, social worker takes second exam for independent licensure LICSW (licensed independent clinical social worker).

Social work schools have a course or two in family therapy. After graduation, students may choose to specialize in couples and family therapy. Like psychiatric and psychological training programs, there is wide variation in the amount of family therapy taught in schools of social work.

Marriage and family therapists (MFTs) have their own organization, the American Association for Marriage and Family Therapy (AAMFT). This organization’s training is specific to families and couples. Members are required to be supervised in clinical practice for 2 years. AAMFT produces the Journal of Marital and Family Therapy. The AAMFT website also lists accredited programs in the United States and Canada.

Two American journals in this area are interdisciplinary: Family Process and Families, Systems & Health. Family Process has broad representation on its board from all disciplines and has a strong focus on family systems research and social justice. Family Process aims to support emerging researchers and clinicians worldwide, and periodically offers grants. Families, Systems & Health is multidisciplinary with a focus on research and clinical practice in medical illness, and health psychology.

The American Family Therapy Academy (AFTA) is the only organization that is interdisciplinary. Founded in 1977, AFTA’s objectives include “the advancement of theories, therapies, research, and professional education that regard the family as a unit in a social context, to make information about family therapy available to practitioners in other fields of knowledge and to the public and to foster collaboration among the medical, psychological, social, legal, and other professions that serve families and the science and practice of family therapy.”

AFTA is outspoken on issues that affect families. For example, its Immigration Position Statement addresses the negative impact of U.S. immigration policy on families and children. AFTA has strong views about the DSM-5, stating that “the current revision of the DSM continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines resulting in invalid diagnostic categories and treatment protocols. The DSM is dominant in determining mental health diagnosis and treatment and is more harmful than helpful in delineating best practices.” The next AFTA conference is in June 2015, and the theme is “Global Ecologies: Connections among Self, Families, Communities, and Cultures.”

Family therapy has grown from a small group of interested academics, mostly psychiatrists, to a large group of interdisciplinary professionals. Today, psychiatrists have less access to family systems training than in previous decades but can still access training. In addition to attending conferences, psychiatrists interested in this area might see whether training programs would accept them into their courses.

For those psychiatrists who have not had formal training during residency training, this review of programs is a good starting point for seeking family systems training.

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of the recently published book Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013).

In the late-20th century, family therapy was a new therapeutic modality. It was an exciting time! Family therapy and the application of systems principles to families was considered “thinking outside the box.” Different schools of family therapy were developed, usually based in an academic center and led by a charismatic leader, often a psychiatrist.

Today, with the rise in the popularity of psychopharmacology and the promise of biological interventions, there are fewer opportunities for family systems training within psychiatric residency programs. In order to receive family systems training, a psychiatrist may decide to enroll in an independent family training institute, such as the Ackerman Institute for the Family in New York. However, there are still some psychiatric residency programs that consider learning to work with families to be an essential psychotherapeutic skill.

Psychiatric training in family therapy

Dr. Ellen Berman, president of the Association of Family Psychiatrists, recently asked family psychiatrists to indicate psychiatric residency programs offering family systems training. Nine programs were identified. Here is a description of each program and contact information:

•  Albert Einstein College of Medicine, New York

“We have a well-established and extensive Family Studies program that is part of the department of psychiatry at Albert Einstein College of Medicine and is well integrated into the residency training program. All residents in the 4 years of the training program at Montefiore Medical Center and Bronx (N.Y.) Psychiatric Center as well as child fellows receive supervision in couples and family therapy, courses, seminars, electives, and more. Faculty and residents have presented different innovative projects related to family and systems at national conferences and have written papers on their clinical work.”

– Contact: [email protected], Director of Family Studies, department of psychiatry, Albert Einstein College of Medicine.

•  McGill University, Montreal

“We have a very active family therapy community in Montreal, with [Dr.] Herta Guttman as our pioneer. At the Jewish General [Hospital] department of psychiatry, we run an [American Association for Marriage and Family Therapy]–accredited postgraduate certificate couple and family therapy program. This program primarily trains community mental health practitioners (social workers, psychologists, etc.), however, we have had psychiatrists take this course. This year, we are training our first Couple and Family Fellow (child psychiatrist) through the department of psychiatry.

In McGill Psychiatry, we have a new family skills teaching module in the McGill Resident Diploma Program. We will provide 3 hours of teaching in the R1 year (basic concepts). In the R2 and R3 years, residents receive training on a range of family therapy topics. The curriculum was inspired by the Group for the Advancement of Psychiatry curriculum. Dr. Nick Casacalenda spearheaded this initiative. There are 3 hours of family teaching in the diploma course module: gender, social, and cultural aspects of psychiatry, and 6 hours in the child psychiatry module.”

– Contact: Sharon Bond, Ph.D.; School of Social Work; Director, Couple and Family Therapy Program.

•  NYU School of Medicine

“I am the director of service at the Roberto Clemente Center in the Lower East Side (now East Village) in Manhattan. The center is part of the departments of mental health of both Gouverneur [Healthcare Services] and Bellevue. We have an academic affiliation with New York University School of Medicine. The center was started about 30 years ago by a psychologist, Jaime Inclan, Ph.D. He was initially was trained by [Dr.] Salvador Minuchin. As a family clinic embedded in the community, we mostly serve minority underserved populations. We provide primary health and mental health services. We have been providing for decades training to medical students, psychology interns, and social work students.”

– Contact: Dr. Miguel Vilaro-Colon, Clinical Assistant Professor of Psychiatry, NYU School of Medicine.

•  Stanford (Calif.) University

“Our 4-year training program in couples and family therapy begins with didactics and family meetings (inpatient) in the first year; didactics and opportunities for a couples and family therapy clinical elective as [postgraduate year]-2s; live case observation in the family therapy program at the [Veterans Affairs] Palo Alto Health Care System, as well as an intensive seminar at Stanford during the PGY-3 year, and supervised outpatient clinical work in Stanford’s Couples and Family Therapy Clinic during the PGY-3 and PGY-4 years. Residents who are interested in child and adolescent psychiatry can focus their PGY-3 rotation on family cases with a child/adolescent focus. An earlier version of this training sequence is described in program for residents is described in ‘A Model for Reintegrating Couples and Family Therapy Training in Psychiatric Residency Programs’ ” (Acad. Psychiatry 2008;32:81-6).

– Contact: Douglas S. Rait, Ph.D., Chief, Couples and Family Therapy Clinic, Clinical Professor of Psychiatry & Behavioral Sciences, Stanford University.

•  University of Pennsylvania Perlman School of Medicine

“The Center for Couples and Adult Families in the department of psychiatry includes a didactic program for residents spanning all 4 years and supervision in PGY-3 and 4. Residents help run multifamily psychoeducation groups in the bipolar clinic, and see couples and families in their outpatient clinics. Our focus is on family inclusion and family psychoeducation for all patients when possible, with couple and adult family therapy when appropriate. Our curriculum is on our website As the clinical director, I work closely with Ellen Berman, who founded the center 5 years ago.”

– Contact: Jacqueline Hudak, Ph.D., LMFT, Center for Couples and Adult Families, Department of Psychiatry, Perelman School of Medicine.

•  Mount Sinai Beth Israel, New York The Family Center for Bipolar provides services to patients with bipolar disorder “within the context of the family.” In addition, Dr. Igor Galynker, who runs the center, gives a series of lectures on family inclusion. The center also has a formal training program in family therapy run by Haya Mermelstein, CSW.

– Contact: Dr. Igor Galynker, professor of psychiatry, Icahn School of Medicine at Mount Sinai; director, the Family Center for Bipolar Disorder; Associate Chairman, Department Of Psychiatry and Behavioral Sciences.

•  Brown University, Providence, R.I.

“We have a formal Family Therapy Training Program in the department of psychiatry at Brown University, based at Rhode Island Hospital.”

– Contact: Dr. Gabor I. Keitner, Associate Chief of Psychiatry, Rhode Island and Miriam Hospitals; Professor, Department of Psychiatry, Brown University.

•  University of Rochester, Institute for the Family

“An emphasis on family is embedded in all of our training. The residents have a formal didactic curriculum and participate in family care and family research. Many of the residents fast track into a child fellowship, which has an extensive program in family therapy.

– Contact: Dr. [email protected], Director of Psychiatry Residency Education, University of Rochester Medical Center.

•  University of Colorado Denver

“Our department offers a unique psychotherapy scholar track. The mission of this track is to offer advanced psychotherapy training to a subgroup of psychiatric residents, within an adult general residency program, who wish to learn and do psychotherapy. Within this track we offer extensive family therapy training. The family therapy component consists of didactics and direct supervision. It runs through the 4 years of residency. There are several experienced family therapists on the faculty who supervise in this program.”

– Contact: Dr. [email protected], Vice Chair, Department of Psychiatry.

A multidisciplinary field

Family systems training occurs in other disciplines: psychology, social work, and marriage and family therapy (MFT) programs. The number of MFT programs across the United States is large, reflecting the demand for family systems therapists.

Psychologists with a special interest in family therapy belong to the American Psychological Association’s Division 43. Division 43 supports family-oriented clinical and scientific activities as well as education and public policy, a journal called the Journal of Family Psychology, and a quarterly newsletter called The Family Psychologist. Many psychologists are trained in family therapy work in primary care settings. The current president of American Psychological Association, Nadine J. Kaslow, Ph.D., is a family therapist who helps underserved and underprivileged populations receive culturally competent, evidence-based, biopsychosocially oriented mental health services.

Social Workers are required to take two exams: one to be “licensed” as an LCSW (licensed clinical social worker) after graduation with a master’s degree. After 3,000 hours of supervised clinical practice, social worker takes second exam for independent licensure LICSW (licensed independent clinical social worker).

Social work schools have a course or two in family therapy. After graduation, students may choose to specialize in couples and family therapy. Like psychiatric and psychological training programs, there is wide variation in the amount of family therapy taught in schools of social work.

Marriage and family therapists (MFTs) have their own organization, the American Association for Marriage and Family Therapy (AAMFT). This organization’s training is specific to families and couples. Members are required to be supervised in clinical practice for 2 years. AAMFT produces the Journal of Marital and Family Therapy. The AAMFT website also lists accredited programs in the United States and Canada.

Two American journals in this area are interdisciplinary: Family Process and Families, Systems & Health. Family Process has broad representation on its board from all disciplines and has a strong focus on family systems research and social justice. Family Process aims to support emerging researchers and clinicians worldwide, and periodically offers grants. Families, Systems & Health is multidisciplinary with a focus on research and clinical practice in medical illness, and health psychology.

The American Family Therapy Academy (AFTA) is the only organization that is interdisciplinary. Founded in 1977, AFTA’s objectives include “the advancement of theories, therapies, research, and professional education that regard the family as a unit in a social context, to make information about family therapy available to practitioners in other fields of knowledge and to the public and to foster collaboration among the medical, psychological, social, legal, and other professions that serve families and the science and practice of family therapy.”

AFTA is outspoken on issues that affect families. For example, its Immigration Position Statement addresses the negative impact of U.S. immigration policy on families and children. AFTA has strong views about the DSM-5, stating that “the current revision of the DSM continues a long history of ignoring research and excluding vital contributions of nonpsychiatric mental health disciplines resulting in invalid diagnostic categories and treatment protocols. The DSM is dominant in determining mental health diagnosis and treatment and is more harmful than helpful in delineating best practices.” The next AFTA conference is in June 2015, and the theme is “Global Ecologies: Connections among Self, Families, Communities, and Cultures.”

Family therapy has grown from a small group of interested academics, mostly psychiatrists, to a large group of interdisciplinary professionals. Today, psychiatrists have less access to family systems training than in previous decades but can still access training. In addition to attending conferences, psychiatrists interested in this area might see whether training programs would accept them into their courses.

For those psychiatrists who have not had formal training during residency training, this review of programs is a good starting point for seeking family systems training.

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of the recently published book Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013).

Neil P. Shah, MD, PhD

NEW YORK—If any oncology drugs warrant a high price, BCR-ABL tyrosine kinase inhibitors (TKIs) could make a strong case, according to a speaker at the NCCN 9th Annual Congress: Hematologic Malignancies.

TKIs have revolutionized the therapeutic landscape in chronic myeloid leukemia (CML), said Neil P. Shah, MD, PhD, of the UCSF

Helen Diller Family Comprehensive Cancer Center in San Francisco.

Five-year overall survival is 93% in CML patients treated with imatinib. And 80,000 people are estimated to be living with CML in 2014, a number that is expected to double by 2035.

Yet the increase in life expectancy places a burden on the healthcare system, Dr Shah said, particularly since the price of BCR-ABL TKIs has risen dramatically.

A year of imatinib therapy circa 2001 cost approximately $30,000, and by 2013, approximately $92,000. Second-generation (2G) TKIs cost even more, at about $115,000 annually, and the third-generation TKI ponatinib costs about $138,000 annually.

Confounding the financial picture will be the advent of generic imatinib, which will be available in the US in early 2016.

Generic imatinib will, presumably, be less expensive than the brand-name drug. However, it is not clear whether it will be as effective or what impact it will have on the 2G and 3G TKIs.

With all that in mind, Dr Shah provided some options for maximizing therapeutic outcomes in a fiscally responsible manner.

He based his potential solutions on evidence-based premises. First, imatinib is a highly active therapy for many chronic-phase CML patients. The 8-year update of the IRIS study shows that 53% of patients sustain complete cytogenetic remission (CCyR) with imatinib.

Second, patients who are likely to do well on TKI therapy can be identified early based on their BCR-ABL PCR levels after 3 months of therapy.

This important 3-month milestone has been incorporated into the NCCN guidelines. Patients who achieve BCR-ABL/ABL levels of 10% or less have a significantly better overall survival than those who have levels greater than 10%.

Third, the ENESTnd and DASISION studies demonstrated that nilotinib and dasatinib elicit achievement of important treatment milestones (PCR<10% at 3 months and CCyR after 12 months) in a significantly higher proportion of patients than imatinib. But to date, neither agent has produced a significant improvement in overall survival.

And fourth, while nilotinib and dasatinib have an undisputable clinical benefit over imatinib in terms of transformation to accelerated phase/blast crisis (AP/BC), these agents cost between $23,000 and $31,000 more than imatinib for an annual course of treatment.

Dr Shah calculated that to achieve approximately 10 fewer AP/BC transformations over 5 years, approximately 300 patients would need to be treated at an additional cost of $37.5 million. This equates to $3.75 million in additional costs for 1 transformation event spared over 5 years.

“We do have to keep in mind transformation events are not cheap,” he said. “So when these happen, patients need to be hospitalized for chemotherapy, typically, or they have to go to allogeneic stem cell transplantation.”

So Dr Shah proffered 3 potential approaches for fiscally sustainable TKI use.

The first approach would be to initiate imatinib in most, if not all, chronic-phase CML patients. If they achieve BCR-ABL levels <10% at 3 months or partial CyR after 12 months, then continue imatinib. If not, switch to a 2G TKI.

Dr Shah noted that 40% to 60% of patients will have a deep, durable response to imatinib.

The second approach would be to initiate 2G TKIs in newly diagnosed patients. And when they achieve CCyR or major molecular response (MMR), enroll them in a clinical trial.

These trials could investigate a switch to imatinib, use of a lower dose of the 2G TKI, a switch to interferon-alfa, the addition of a CYP3A4 inhibitor (such as grapefruit) and a lower dose, or another investigational option.

And the third approach would be to initiate imatinib or an approved 2G TKI in newly diagnosed patients. When they achieve targeted molecular remission, enroll them in a treatment-discontinuation trial.

Dr Shah pointed out that in the STIM study, 61% of patients remained in complete molecular remission 60 months after discontinuing imatinib, and 40% experienced treatment-free survival.

Taking into account the cost of imatinib and the number of months without treatment, STIM investigators estimated the savings to be €4,587,500, or approximately $6 to $7 million.

Patients who relapsed 6 to 9 months after discontinuing imatinib tended to respond well to a rechallenge with imatinib. But Dr Shah cautioned that, at present, discontinuation should only be performed in the context of a clinical trial.

Neil P. Shah, MD, PhD

NEW YORK—If any oncology drugs warrant a high price, BCR-ABL tyrosine kinase inhibitors (TKIs) could make a strong case, according to a speaker at the NCCN 9th Annual Congress: Hematologic Malignancies.

TKIs have revolutionized the therapeutic landscape in chronic myeloid leukemia (CML), said Neil P. Shah, MD, PhD, of the UCSF

Helen Diller Family Comprehensive Cancer Center in San Francisco.

Five-year overall survival is 93% in CML patients treated with imatinib. And 80,000 people are estimated to be living with CML in 2014, a number that is expected to double by 2035.

Yet the increase in life expectancy places a burden on the healthcare system, Dr Shah said, particularly since the price of BCR-ABL TKIs has risen dramatically.

A year of imatinib therapy circa 2001 cost approximately $30,000, and by 2013, approximately $92,000. Second-generation (2G) TKIs cost even more, at about $115,000 annually, and the third-generation TKI ponatinib costs about $138,000 annually.

Confounding the financial picture will be the advent of generic imatinib, which will be available in the US in early 2016.

Generic imatinib will, presumably, be less expensive than the brand-name drug. However, it is not clear whether it will be as effective or what impact it will have on the 2G and 3G TKIs.

With all that in mind, Dr Shah provided some options for maximizing therapeutic outcomes in a fiscally responsible manner.

He based his potential solutions on evidence-based premises. First, imatinib is a highly active therapy for many chronic-phase CML patients. The 8-year update of the IRIS study shows that 53% of patients sustain complete cytogenetic remission (CCyR) with imatinib.

Second, patients who are likely to do well on TKI therapy can be identified early based on their BCR-ABL PCR levels after 3 months of therapy.

This important 3-month milestone has been incorporated into the NCCN guidelines. Patients who achieve BCR-ABL/ABL levels of 10% or less have a significantly better overall survival than those who have levels greater than 10%.

Third, the ENESTnd and DASISION studies demonstrated that nilotinib and dasatinib elicit achievement of important treatment milestones (PCR<10% at 3 months and CCyR after 12 months) in a significantly higher proportion of patients than imatinib. But to date, neither agent has produced a significant improvement in overall survival.

And fourth, while nilotinib and dasatinib have an undisputable clinical benefit over imatinib in terms of transformation to accelerated phase/blast crisis (AP/BC), these agents cost between $23,000 and $31,000 more than imatinib for an annual course of treatment.

Dr Shah calculated that to achieve approximately 10 fewer AP/BC transformations over 5 years, approximately 300 patients would need to be treated at an additional cost of $37.5 million. This equates to $3.75 million in additional costs for 1 transformation event spared over 5 years.

“We do have to keep in mind transformation events are not cheap,” he said. “So when these happen, patients need to be hospitalized for chemotherapy, typically, or they have to go to allogeneic stem cell transplantation.”

So Dr Shah proffered 3 potential approaches for fiscally sustainable TKI use.

The first approach would be to initiate imatinib in most, if not all, chronic-phase CML patients. If they achieve BCR-ABL levels <10% at 3 months or partial CyR after 12 months, then continue imatinib. If not, switch to a 2G TKI.

Dr Shah noted that 40% to 60% of patients will have a deep, durable response to imatinib.

The second approach would be to initiate 2G TKIs in newly diagnosed patients. And when they achieve CCyR or major molecular response (MMR), enroll them in a clinical trial.

These trials could investigate a switch to imatinib, use of a lower dose of the 2G TKI, a switch to interferon-alfa, the addition of a CYP3A4 inhibitor (such as grapefruit) and a lower dose, or another investigational option.

And the third approach would be to initiate imatinib or an approved 2G TKI in newly diagnosed patients. When they achieve targeted molecular remission, enroll them in a treatment-discontinuation trial.

Dr Shah pointed out that in the STIM study, 61% of patients remained in complete molecular remission 60 months after discontinuing imatinib, and 40% experienced treatment-free survival.

Taking into account the cost of imatinib and the number of months without treatment, STIM investigators estimated the savings to be €4,587,500, or approximately $6 to $7 million.

Patients who relapsed 6 to 9 months after discontinuing imatinib tended to respond well to a rechallenge with imatinib. But Dr Shah cautioned that, at present, discontinuation should only be performed in the context of a clinical trial.

Neil P. Shah, MD, PhD

NEW YORK—If any oncology drugs warrant a high price, BCR-ABL tyrosine kinase inhibitors (TKIs) could make a strong case, according to a speaker at the NCCN 9th Annual Congress: Hematologic Malignancies.

TKIs have revolutionized the therapeutic landscape in chronic myeloid leukemia (CML), said Neil P. Shah, MD, PhD, of the UCSF

Helen Diller Family Comprehensive Cancer Center in San Francisco.

Five-year overall survival is 93% in CML patients treated with imatinib. And 80,000 people are estimated to be living with CML in 2014, a number that is expected to double by 2035.

Yet the increase in life expectancy places a burden on the healthcare system, Dr Shah said, particularly since the price of BCR-ABL TKIs has risen dramatically.

A year of imatinib therapy circa 2001 cost approximately $30,000, and by 2013, approximately $92,000. Second-generation (2G) TKIs cost even more, at about $115,000 annually, and the third-generation TKI ponatinib costs about $138,000 annually.

Confounding the financial picture will be the advent of generic imatinib, which will be available in the US in early 2016.

Generic imatinib will, presumably, be less expensive than the brand-name drug. However, it is not clear whether it will be as effective or what impact it will have on the 2G and 3G TKIs.

With all that in mind, Dr Shah provided some options for maximizing therapeutic outcomes in a fiscally responsible manner.

He based his potential solutions on evidence-based premises. First, imatinib is a highly active therapy for many chronic-phase CML patients. The 8-year update of the IRIS study shows that 53% of patients sustain complete cytogenetic remission (CCyR) with imatinib.

Second, patients who are likely to do well on TKI therapy can be identified early based on their BCR-ABL PCR levels after 3 months of therapy.

This important 3-month milestone has been incorporated into the NCCN guidelines. Patients who achieve BCR-ABL/ABL levels of 10% or less have a significantly better overall survival than those who have levels greater than 10%.

Third, the ENESTnd and DASISION studies demonstrated that nilotinib and dasatinib elicit achievement of important treatment milestones (PCR<10% at 3 months and CCyR after 12 months) in a significantly higher proportion of patients than imatinib. But to date, neither agent has produced a significant improvement in overall survival.

And fourth, while nilotinib and dasatinib have an undisputable clinical benefit over imatinib in terms of transformation to accelerated phase/blast crisis (AP/BC), these agents cost between $23,000 and $31,000 more than imatinib for an annual course of treatment.

Dr Shah calculated that to achieve approximately 10 fewer AP/BC transformations over 5 years, approximately 300 patients would need to be treated at an additional cost of $37.5 million. This equates to $3.75 million in additional costs for 1 transformation event spared over 5 years.

“We do have to keep in mind transformation events are not cheap,” he said. “So when these happen, patients need to be hospitalized for chemotherapy, typically, or they have to go to allogeneic stem cell transplantation.”

So Dr Shah proffered 3 potential approaches for fiscally sustainable TKI use.

The first approach would be to initiate imatinib in most, if not all, chronic-phase CML patients. If they achieve BCR-ABL levels <10% at 3 months or partial CyR after 12 months, then continue imatinib. If not, switch to a 2G TKI.

Dr Shah noted that 40% to 60% of patients will have a deep, durable response to imatinib.

The second approach would be to initiate 2G TKIs in newly diagnosed patients. And when they achieve CCyR or major molecular response (MMR), enroll them in a clinical trial.

These trials could investigate a switch to imatinib, use of a lower dose of the 2G TKI, a switch to interferon-alfa, the addition of a CYP3A4 inhibitor (such as grapefruit) and a lower dose, or another investigational option.

And the third approach would be to initiate imatinib or an approved 2G TKI in newly diagnosed patients. When they achieve targeted molecular remission, enroll them in a treatment-discontinuation trial.

Dr Shah pointed out that in the STIM study, 61% of patients remained in complete molecular remission 60 months after discontinuing imatinib, and 40% experienced treatment-free survival.

Taking into account the cost of imatinib and the number of months without treatment, STIM investigators estimated the savings to be €4,587,500, or approximately $6 to $7 million.

Patients who relapsed 6 to 9 months after discontinuing imatinib tended to respond well to a rechallenge with imatinib. But Dr Shah cautioned that, at present, discontinuation should only be performed in the context of a clinical trial.

The Immunization Action Coalition (IAC) works in cadence with the Centers for Disease Control and Prevention (CDC) to offer health care professionals in both the public and private sectors the most up-to-date immunization information available in one retrievable location. This well established website, http://www.immunize.org, serves more than 14,000 visitors every day.

Talking About Vaccines provides research and guidelines by an assortment of nationally recognized institutions, including the IAC, CDC, and many others in response to common concerns.

Within Clinic Resources, users can access how-to documents on providing vaccines at a clinic or nontraditional setting. Also available are patient and staff handouts, including indexed vaccines (eg, human papillomavirus and tetanus) and topics such as needle safety.

The Immunization Action Coalition (IAC) works in cadence with the Centers for Disease Control and Prevention (CDC) to offer health care professionals in both the public and private sectors the most up-to-date immunization information available in one retrievable location. This well established website, http://www.immunize.org, serves more than 14,000 visitors every day.

Talking About Vaccines provides research and guidelines by an assortment of nationally recognized institutions, including the IAC, CDC, and many others in response to common concerns.

Within Clinic Resources, users can access how-to documents on providing vaccines at a clinic or nontraditional setting. Also available are patient and staff handouts, including indexed vaccines (eg, human papillomavirus and tetanus) and topics such as needle safety.

The Immunization Action Coalition (IAC) works in cadence with the Centers for Disease Control and Prevention (CDC) to offer health care professionals in both the public and private sectors the most up-to-date immunization information available in one retrievable location. This well established website, http://www.immunize.org, serves more than 14,000 visitors every day.

Talking About Vaccines provides research and guidelines by an assortment of nationally recognized institutions, including the IAC, CDC, and many others in response to common concerns.

Within Clinic Resources, users can access how-to documents on providing vaccines at a clinic or nontraditional setting. Also available are patient and staff handouts, including indexed vaccines (eg, human papillomavirus and tetanus) and topics such as needle safety.

Preparing for transplant

Credit: Chad McNeeley

NEW YORK—A debate on the pros and cons of upfront transplant in symptomatic multiple myeloma (MM) yielded a split decision from the audience during the NCCN 9th Annual Congress: Hematologic Malignancies.

Sergio Giralt, MD, of Memorial Sloan Kettering Cancer Center in New York, argued for upfront transplant, pointing out that long-term MM survivors have transplant as upfront therapy.

Kenneth Anderson, MD, of Dana Farber/Brigham and Women’s Cancer Center in Boston, took the stance that, in the past 10 years, there has been a

revolution in novel therapies that has significantly improved survival in MM.

For upfront transplant

Dr Giralt cited the 36-month follow-up of the E4A03 landmark analysis of patients who went off therapy after 4 cycles of lenalidomide/dexamethasone to pursue early stem cell transplant and those who continued treatment until disease progression.

Regardless of whether the patients were younger than 65 years or between 65 and 70, the patients who had an early transplant had superior progression-free survival (PFS) and overall survival (OS) compared to those who did not.

Dr Giralt added that bortezomib should be a component of induction therapy prior to autologous stem cell transplant (ASCT). Even though there is no survival benefit with bortezomib-based regimens, he said, there is significant improvement in PFS, as shown in a meta-analysis of phase 3 European studies.

The E4A03 landmark study also determined that the more intense the treatment, the better the outcome. So patients with double ASCT had a significantly longer PFS than patients who only had a single transplant.

This held true for OS as well, and included patients with 17p deletion and/or t(4;14) who failed to achieve complete remission after bortezomib-based induction regimens.

An analysis of 27,987 MM patients with a median age of 68 years (range, 19 to 90) revealed that of the patients who survived 10 years or more, 16.5% had ASCT as part of their initial therapy.

Dr Giralt concluded that the preponderance of evidence supports high-dose melphalan and ASCT as upfront consolidation therapy for MM. And until results of randomized trials investigating combination therapies are reported, melphalan consolidation should be considered the standard of care for all eligible patients with MM.

Against upfront transplant

Dr Anderson countered with data showing limited or no improvement in survival with ASCT, including evidence from studies by Attal, Fermand, Blade, Child, and Barlogie.

ASCT confers only modest PFS advantage, he said, showing results of the Barlogie study in which patients undergoing ASCT had a 25-month PFS, compared with a 21-month PFS with VBMCP (vincristine, carmustine, melphalan, cyclophosphamide, and prednisone).

“In the last 10 to 15 years, there has been a revolution in myeloma,” Dr Anderson said. “We have a lot of novel agents here today, and we have even more coming. It’s a hugely exciting time.”

Dr Anderson pointed out that since the introduction of novel agents, survival has improved between 2006 and 2010, compared to the period between 2001 and 2005, and particularly in patients older than 65 years (P=0.001).

Transplant has also changed, he said. Novel therapies have been integrated into the transplant paradigm, either before, as induction and consolidation therapy, or after, as maintenance. He indicated that this begs the question as to whether we really need the transplant component.

There has also been unprecedented use of triplets in combination therapy, Dr Anderson said, resulting in overall response rates upwards of 90%. For example, carfilzomib in combination with lenalidomide and dexamethasone prompted an overall response rate of 94%, with a stringent complete response (CR), CR, and near CR of 53%.

“It’s a new day in myeloma,” he said. “It’s taken us a long time, but we’re worrying about minimal residual disease (MRD) now. We’re worried about getting to the endpoint of 1 myeloma cell in 1 million normal cells.”

The point is, he added, that with novel therapies, such as carfilzomib, lenalidomide, and dexamethasone, patients who achieve a complete response can become MRD negative, suggesting an unprecedented extent of response without transplant.

MRD negativity may also be accomplished with oral agents, such as ixazomib. The depth of response with ixazomib increases over the course of treatment, with 27% achieving stringent CR or CR with a median duration of response of 13.8 months, and 82% of patients attaining MRD-negative status.

“In the absence of transplant,” Dr Anderson said, “this is an unprecedented response.”

Dr Anderson also pointed out that in the era of novel agents, there is no difference in outcome between early or delayed transplant. The 4-year OS in transplant-eligible patients who received initial therapy with lenalidomide was 80%, regardless of the timing of ASCT.

And in one trial, patients who received a delayed transplant fared better in OS than those transplanted early.

Dr Anderson said there is a parallel, international phase 3 study underway (IFM/DFCI2009) that will provide an answer to the debate on upfront transplant in the not-too-distant future.

Preparing for transplant

Credit: Chad McNeeley

NEW YORK—A debate on the pros and cons of upfront transplant in symptomatic multiple myeloma (MM) yielded a split decision from the audience during the NCCN 9th Annual Congress: Hematologic Malignancies.

Sergio Giralt, MD, of Memorial Sloan Kettering Cancer Center in New York, argued for upfront transplant, pointing out that long-term MM survivors have transplant as upfront therapy.

Kenneth Anderson, MD, of Dana Farber/Brigham and Women’s Cancer Center in Boston, took the stance that, in the past 10 years, there has been a

revolution in novel therapies that has significantly improved survival in MM.

For upfront transplant

Dr Giralt cited the 36-month follow-up of the E4A03 landmark analysis of patients who went off therapy after 4 cycles of lenalidomide/dexamethasone to pursue early stem cell transplant and those who continued treatment until disease progression.

Regardless of whether the patients were younger than 65 years or between 65 and 70, the patients who had an early transplant had superior progression-free survival (PFS) and overall survival (OS) compared to those who did not.

Dr Giralt added that bortezomib should be a component of induction therapy prior to autologous stem cell transplant (ASCT). Even though there is no survival benefit with bortezomib-based regimens, he said, there is significant improvement in PFS, as shown in a meta-analysis of phase 3 European studies.

The E4A03 landmark study also determined that the more intense the treatment, the better the outcome. So patients with double ASCT had a significantly longer PFS than patients who only had a single transplant.

This held true for OS as well, and included patients with 17p deletion and/or t(4;14) who failed to achieve complete remission after bortezomib-based induction regimens.

An analysis of 27,987 MM patients with a median age of 68 years (range, 19 to 90) revealed that of the patients who survived 10 years or more, 16.5% had ASCT as part of their initial therapy.

Dr Giralt concluded that the preponderance of evidence supports high-dose melphalan and ASCT as upfront consolidation therapy for MM. And until results of randomized trials investigating combination therapies are reported, melphalan consolidation should be considered the standard of care for all eligible patients with MM.

Against upfront transplant

Dr Anderson countered with data showing limited or no improvement in survival with ASCT, including evidence from studies by Attal, Fermand, Blade, Child, and Barlogie.

ASCT confers only modest PFS advantage, he said, showing results of the Barlogie study in which patients undergoing ASCT had a 25-month PFS, compared with a 21-month PFS with VBMCP (vincristine, carmustine, melphalan, cyclophosphamide, and prednisone).

“In the last 10 to 15 years, there has been a revolution in myeloma,” Dr Anderson said. “We have a lot of novel agents here today, and we have even more coming. It’s a hugely exciting time.”

Dr Anderson pointed out that since the introduction of novel agents, survival has improved between 2006 and 2010, compared to the period between 2001 and 2005, and particularly in patients older than 65 years (P=0.001).

Transplant has also changed, he said. Novel therapies have been integrated into the transplant paradigm, either before, as induction and consolidation therapy, or after, as maintenance. He indicated that this begs the question as to whether we really need the transplant component.

There has also been unprecedented use of triplets in combination therapy, Dr Anderson said, resulting in overall response rates upwards of 90%. For example, carfilzomib in combination with lenalidomide and dexamethasone prompted an overall response rate of 94%, with a stringent complete response (CR), CR, and near CR of 53%.

“It’s a new day in myeloma,” he said. “It’s taken us a long time, but we’re worrying about minimal residual disease (MRD) now. We’re worried about getting to the endpoint of 1 myeloma cell in 1 million normal cells.”

The point is, he added, that with novel therapies, such as carfilzomib, lenalidomide, and dexamethasone, patients who achieve a complete response can become MRD negative, suggesting an unprecedented extent of response without transplant.

MRD negativity may also be accomplished with oral agents, such as ixazomib. The depth of response with ixazomib increases over the course of treatment, with 27% achieving stringent CR or CR with a median duration of response of 13.8 months, and 82% of patients attaining MRD-negative status.

“In the absence of transplant,” Dr Anderson said, “this is an unprecedented response.”

Dr Anderson also pointed out that in the era of novel agents, there is no difference in outcome between early or delayed transplant. The 4-year OS in transplant-eligible patients who received initial therapy with lenalidomide was 80%, regardless of the timing of ASCT.

And in one trial, patients who received a delayed transplant fared better in OS than those transplanted early.

Dr Anderson said there is a parallel, international phase 3 study underway (IFM/DFCI2009) that will provide an answer to the debate on upfront transplant in the not-too-distant future.

Preparing for transplant

Credit: Chad McNeeley

NEW YORK—A debate on the pros and cons of upfront transplant in symptomatic multiple myeloma (MM) yielded a split decision from the audience during the NCCN 9th Annual Congress: Hematologic Malignancies.

Sergio Giralt, MD, of Memorial Sloan Kettering Cancer Center in New York, argued for upfront transplant, pointing out that long-term MM survivors have transplant as upfront therapy.

Kenneth Anderson, MD, of Dana Farber/Brigham and Women’s Cancer Center in Boston, took the stance that, in the past 10 years, there has been a

revolution in novel therapies that has significantly improved survival in MM.

For upfront transplant

Dr Giralt cited the 36-month follow-up of the E4A03 landmark analysis of patients who went off therapy after 4 cycles of lenalidomide/dexamethasone to pursue early stem cell transplant and those who continued treatment until disease progression.

Regardless of whether the patients were younger than 65 years or between 65 and 70, the patients who had an early transplant had superior progression-free survival (PFS) and overall survival (OS) compared to those who did not.

Dr Giralt added that bortezomib should be a component of induction therapy prior to autologous stem cell transplant (ASCT). Even though there is no survival benefit with bortezomib-based regimens, he said, there is significant improvement in PFS, as shown in a meta-analysis of phase 3 European studies.

The E4A03 landmark study also determined that the more intense the treatment, the better the outcome. So patients with double ASCT had a significantly longer PFS than patients who only had a single transplant.

This held true for OS as well, and included patients with 17p deletion and/or t(4;14) who failed to achieve complete remission after bortezomib-based induction regimens.

An analysis of 27,987 MM patients with a median age of 68 years (range, 19 to 90) revealed that of the patients who survived 10 years or more, 16.5% had ASCT as part of their initial therapy.

Dr Giralt concluded that the preponderance of evidence supports high-dose melphalan and ASCT as upfront consolidation therapy for MM. And until results of randomized trials investigating combination therapies are reported, melphalan consolidation should be considered the standard of care for all eligible patients with MM.

Against upfront transplant

Dr Anderson countered with data showing limited or no improvement in survival with ASCT, including evidence from studies by Attal, Fermand, Blade, Child, and Barlogie.

ASCT confers only modest PFS advantage, he said, showing results of the Barlogie study in which patients undergoing ASCT had a 25-month PFS, compared with a 21-month PFS with VBMCP (vincristine, carmustine, melphalan, cyclophosphamide, and prednisone).

“In the last 10 to 15 years, there has been a revolution in myeloma,” Dr Anderson said. “We have a lot of novel agents here today, and we have even more coming. It’s a hugely exciting time.”

Dr Anderson pointed out that since the introduction of novel agents, survival has improved between 2006 and 2010, compared to the period between 2001 and 2005, and particularly in patients older than 65 years (P=0.001).

Transplant has also changed, he said. Novel therapies have been integrated into the transplant paradigm, either before, as induction and consolidation therapy, or after, as maintenance. He indicated that this begs the question as to whether we really need the transplant component.

There has also been unprecedented use of triplets in combination therapy, Dr Anderson said, resulting in overall response rates upwards of 90%. For example, carfilzomib in combination with lenalidomide and dexamethasone prompted an overall response rate of 94%, with a stringent complete response (CR), CR, and near CR of 53%.

“It’s a new day in myeloma,” he said. “It’s taken us a long time, but we’re worrying about minimal residual disease (MRD) now. We’re worried about getting to the endpoint of 1 myeloma cell in 1 million normal cells.”

The point is, he added, that with novel therapies, such as carfilzomib, lenalidomide, and dexamethasone, patients who achieve a complete response can become MRD negative, suggesting an unprecedented extent of response without transplant.

MRD negativity may also be accomplished with oral agents, such as ixazomib. The depth of response with ixazomib increases over the course of treatment, with 27% achieving stringent CR or CR with a median duration of response of 13.8 months, and 82% of patients attaining MRD-negative status.

“In the absence of transplant,” Dr Anderson said, “this is an unprecedented response.”

Dr Anderson also pointed out that in the era of novel agents, there is no difference in outcome between early or delayed transplant. The 4-year OS in transplant-eligible patients who received initial therapy with lenalidomide was 80%, regardless of the timing of ASCT.

And in one trial, patients who received a delayed transplant fared better in OS than those transplanted early.

Dr Anderson said there is a parallel, international phase 3 study underway (IFM/DFCI2009) that will provide an answer to the debate on upfront transplant in the not-too-distant future.

Multiple myeloma

PHILADELPHIA—A drug that targets the ribosome may be active in a broad range of hematologic malignancies, researchers say.

The drug, CX-5461, inhibits the protein RNA polymerase I (Pol I), which is consistently upregulated in hematologic and other cancers.

CX-5461 significantly prolonged survival in mouse models of refractory acute myeloid leukemia (AML) and multiple myeloma (MM). It also synergized with everolimus to extend survival in mice with B-cell lymphoma.

Furthermore, the drug did not elicit severe adverse effects.

“We were excited to find that therapeutic doses of CX-5461 had little effect on normal cells in our experiments,” said Ross D. Hannan, PhD, of the Peter MacCallum Cancer Centre in Melbourne, Australia,

“Prior to these studies, few people would have guessed that such a therapeutic window could be obtained by targeting a so-called house-keeping protein that is essential to all cells for survival.”

Dr Hannan and his colleagues presented these findings in a poster at the AACR conference Hematologic Malignancies: Translating Discoveries to Novel Therapies.

The researchers previously showed that cancer cells are much more dependent on ribosome biogenesis than normal cells. And blocking the accelerated reading of ribosomal genes in mice—using CX5461—can cause lymphoma and leukemia cells to die, while sparing normal cells.

With their latest research, the group expanded upon these findings by testing CX-5461 in MLL-driven AML, V*κ-Myc-driven MM, and Eμ-Myc lymphoma.

They found that CX-5461 improved overall survival in MLL/ENL Nras leukemic mice, compared to placebo and standard therapy. The median survival was 17 days for vehicle-treated mice, 21 days for mice treated with cytarabine and doxorubicin, and 36 days for mice that received CX-5461 (P<0.0001 for vehicle vs CX-5461).

CX-5461 treated MLL-driven AML by inducing apoptosis, delaying cell-cycle progression, and promoting differentiation.

The researchers also found the therapeutic benefit of CX-5461 is not p53-dependent, which contradicts their previous findings. Human AML cell lines and primary patient samples were sensitive to CX-5461 independent of p53 status.

And MLL/ENL Nras p53^-/- leukemic mice had significantly prolonged survival when treated with CX-5461, compared to vehicle-treated controls. The median survival was 11 days and 24 days, respectively (P<0.0001).

Likewise, CX-5461 significantly prolonged survival in mice bearing V*κ-Myc MM. The median survival was 103.5 days for controls and 175 days for mice that received CX-5461 (P<0.0001).

Finally, the researchers showed that CX-5461 synergizes with everolimus to treat Eμ-Myc lymphoma. The median survival was 15 days in control mice, 18 days in mice that received everolimus, 32 days in mice treated with CX-5461, and 54 days in mice that received both drugs (P<0.0001 for CX-5461 vs the combination).

“These results provide further rationale for the first-in-human phase 1 clinical trial that we initiated in July 2013 testing CX-5461 for patients with advanced hematological malignancies, including AML and multiple myeloma,” Dr Hannan said.

His group’s preclinical research was funded by the National Health and Medical Research Council, Australia; the Leukaemia Foundation of Australia; and Cancer Council Victoria, Melbourne, Australia. Senhwa Biosciences, the makers of CX-5461, provided the drug.

Multiple myeloma

PHILADELPHIA—A drug that targets the ribosome may be active in a broad range of hematologic malignancies, researchers say.

The drug, CX-5461, inhibits the protein RNA polymerase I (Pol I), which is consistently upregulated in hematologic and other cancers.

CX-5461 significantly prolonged survival in mouse models of refractory acute myeloid leukemia (AML) and multiple myeloma (MM). It also synergized with everolimus to extend survival in mice with B-cell lymphoma.

Furthermore, the drug did not elicit severe adverse effects.

“We were excited to find that therapeutic doses of CX-5461 had little effect on normal cells in our experiments,” said Ross D. Hannan, PhD, of the Peter MacCallum Cancer Centre in Melbourne, Australia,

“Prior to these studies, few people would have guessed that such a therapeutic window could be obtained by targeting a so-called house-keeping protein that is essential to all cells for survival.”

Dr Hannan and his colleagues presented these findings in a poster at the AACR conference Hematologic Malignancies: Translating Discoveries to Novel Therapies.

The researchers previously showed that cancer cells are much more dependent on ribosome biogenesis than normal cells. And blocking the accelerated reading of ribosomal genes in mice—using CX5461—can cause lymphoma and leukemia cells to die, while sparing normal cells.

With their latest research, the group expanded upon these findings by testing CX-5461 in MLL-driven AML, V*κ-Myc-driven MM, and Eμ-Myc lymphoma.

They found that CX-5461 improved overall survival in MLL/ENL Nras leukemic mice, compared to placebo and standard therapy. The median survival was 17 days for vehicle-treated mice, 21 days for mice treated with cytarabine and doxorubicin, and 36 days for mice that received CX-5461 (P<0.0001 for vehicle vs CX-5461).

CX-5461 treated MLL-driven AML by inducing apoptosis, delaying cell-cycle progression, and promoting differentiation.

The researchers also found the therapeutic benefit of CX-5461 is not p53-dependent, which contradicts their previous findings. Human AML cell lines and primary patient samples were sensitive to CX-5461 independent of p53 status.

And MLL/ENL Nras p53^-/- leukemic mice had significantly prolonged survival when treated with CX-5461, compared to vehicle-treated controls. The median survival was 11 days and 24 days, respectively (P<0.0001).

Likewise, CX-5461 significantly prolonged survival in mice bearing V*κ-Myc MM. The median survival was 103.5 days for controls and 175 days for mice that received CX-5461 (P<0.0001).

Finally, the researchers showed that CX-5461 synergizes with everolimus to treat Eμ-Myc lymphoma. The median survival was 15 days in control mice, 18 days in mice that received everolimus, 32 days in mice treated with CX-5461, and 54 days in mice that received both drugs (P<0.0001 for CX-5461 vs the combination).

“These results provide further rationale for the first-in-human phase 1 clinical trial that we initiated in July 2013 testing CX-5461 for patients with advanced hematological malignancies, including AML and multiple myeloma,” Dr Hannan said.

His group’s preclinical research was funded by the National Health and Medical Research Council, Australia; the Leukaemia Foundation of Australia; and Cancer Council Victoria, Melbourne, Australia. Senhwa Biosciences, the makers of CX-5461, provided the drug.

Multiple myeloma

PHILADELPHIA—A drug that targets the ribosome may be active in a broad range of hematologic malignancies, researchers say.

The drug, CX-5461, inhibits the protein RNA polymerase I (Pol I), which is consistently upregulated in hematologic and other cancers.

CX-5461 significantly prolonged survival in mouse models of refractory acute myeloid leukemia (AML) and multiple myeloma (MM). It also synergized with everolimus to extend survival in mice with B-cell lymphoma.

Furthermore, the drug did not elicit severe adverse effects.

“We were excited to find that therapeutic doses of CX-5461 had little effect on normal cells in our experiments,” said Ross D. Hannan, PhD, of the Peter MacCallum Cancer Centre in Melbourne, Australia,

“Prior to these studies, few people would have guessed that such a therapeutic window could be obtained by targeting a so-called house-keeping protein that is essential to all cells for survival.”

Dr Hannan and his colleagues presented these findings in a poster at the AACR conference Hematologic Malignancies: Translating Discoveries to Novel Therapies.

The researchers previously showed that cancer cells are much more dependent on ribosome biogenesis than normal cells. And blocking the accelerated reading of ribosomal genes in mice—using CX5461—can cause lymphoma and leukemia cells to die, while sparing normal cells.

With their latest research, the group expanded upon these findings by testing CX-5461 in MLL-driven AML, V*κ-Myc-driven MM, and Eμ-Myc lymphoma.

They found that CX-5461 improved overall survival in MLL/ENL Nras leukemic mice, compared to placebo and standard therapy. The median survival was 17 days for vehicle-treated mice, 21 days for mice treated with cytarabine and doxorubicin, and 36 days for mice that received CX-5461 (P<0.0001 for vehicle vs CX-5461).

CX-5461 treated MLL-driven AML by inducing apoptosis, delaying cell-cycle progression, and promoting differentiation.

The researchers also found the therapeutic benefit of CX-5461 is not p53-dependent, which contradicts their previous findings. Human AML cell lines and primary patient samples were sensitive to CX-5461 independent of p53 status.

And MLL/ENL Nras p53^-/- leukemic mice had significantly prolonged survival when treated with CX-5461, compared to vehicle-treated controls. The median survival was 11 days and 24 days, respectively (P<0.0001).

Likewise, CX-5461 significantly prolonged survival in mice bearing V*κ-Myc MM. The median survival was 103.5 days for controls and 175 days for mice that received CX-5461 (P<0.0001).

Finally, the researchers showed that CX-5461 synergizes with everolimus to treat Eμ-Myc lymphoma. The median survival was 15 days in control mice, 18 days in mice that received everolimus, 32 days in mice treated with CX-5461, and 54 days in mice that received both drugs (P<0.0001 for CX-5461 vs the combination).

“These results provide further rationale for the first-in-human phase 1 clinical trial that we initiated in July 2013 testing CX-5461 for patients with advanced hematological malignancies, including AML and multiple myeloma,” Dr Hannan said.

His group’s preclinical research was funded by the National Health and Medical Research Council, Australia; the Leukaemia Foundation of Australia; and Cancer Council Victoria, Melbourne, Australia. Senhwa Biosciences, the makers of CX-5461, provided the drug.

Delaying kidney transplantation to allow for quiescence of systemic lupus erythematosus–related immune activity in patients with lupus nephritis and end-stage renal disease does not appear to improve graft outcomes, according to an analysis of national surveillance data.

Of 4,743 transplant recipients with lupus nephritis and end-stage renal disease (LN-ESRD), 1,239 experienced graft failure. Overall, wait times of 3-12 months and 12-24 months were associated with 25% and 37% increased risk of graft failure, respectively, compared with wait times of less than 3 months, after adjustment for age, race, insurance, hemoglobin, and donor type.

A similar pattern was seen in white patients, except that wait times of more than 36 months in white patients were associated with a near doubling of graft failure risk (hazard ratio, 1.98), Laura C. Plantinga of Emory University, Atlanta, and her colleagues reported (Arthritis Care Res. 2014 Sept. 23 [doi:10.1002/acr.22482]).

Among black patients, longer wait times were not associated with graft failure in the adjusted analysis, and, in fact, there was a nonstatistically significant suggestion of a protective effect for wait time of 2 years or more. This finding may reflect unexplained differences in disease pathology between white and black LN-ESRD patients, the investigators said, adding that there was no increased risk of graft failure in black patients who were transplanted early.

“Our results suggest U.S. recommendations for transplantation in LN-ESRD may not align with evidence from the target population,” they said, noting that the results should be considered hypotheses-generating because of the limitations of the study and that additional study is needed to examine the potential confounding effects of clinically recognized SLE activity on the associations observed in this study.

Some of the investigators were supported through grants from the National Institutes of Health.

Delaying kidney transplantation to allow for quiescence of systemic lupus erythematosus–related immune activity in patients with lupus nephritis and end-stage renal disease does not appear to improve graft outcomes, according to an analysis of national surveillance data.

Of 4,743 transplant recipients with lupus nephritis and end-stage renal disease (LN-ESRD), 1,239 experienced graft failure. Overall, wait times of 3-12 months and 12-24 months were associated with 25% and 37% increased risk of graft failure, respectively, compared with wait times of less than 3 months, after adjustment for age, race, insurance, hemoglobin, and donor type.

A similar pattern was seen in white patients, except that wait times of more than 36 months in white patients were associated with a near doubling of graft failure risk (hazard ratio, 1.98), Laura C. Plantinga of Emory University, Atlanta, and her colleagues reported (Arthritis Care Res. 2014 Sept. 23 [doi:10.1002/acr.22482]).

Among black patients, longer wait times were not associated with graft failure in the adjusted analysis, and, in fact, there was a nonstatistically significant suggestion of a protective effect for wait time of 2 years or more. This finding may reflect unexplained differences in disease pathology between white and black LN-ESRD patients, the investigators said, adding that there was no increased risk of graft failure in black patients who were transplanted early.

“Our results suggest U.S. recommendations for transplantation in LN-ESRD may not align with evidence from the target population,” they said, noting that the results should be considered hypotheses-generating because of the limitations of the study and that additional study is needed to examine the potential confounding effects of clinically recognized SLE activity on the associations observed in this study.

Some of the investigators were supported through grants from the National Institutes of Health.

Delaying kidney transplantation to allow for quiescence of systemic lupus erythematosus–related immune activity in patients with lupus nephritis and end-stage renal disease does not appear to improve graft outcomes, according to an analysis of national surveillance data.

Of 4,743 transplant recipients with lupus nephritis and end-stage renal disease (LN-ESRD), 1,239 experienced graft failure. Overall, wait times of 3-12 months and 12-24 months were associated with 25% and 37% increased risk of graft failure, respectively, compared with wait times of less than 3 months, after adjustment for age, race, insurance, hemoglobin, and donor type.

A similar pattern was seen in white patients, except that wait times of more than 36 months in white patients were associated with a near doubling of graft failure risk (hazard ratio, 1.98), Laura C. Plantinga of Emory University, Atlanta, and her colleagues reported (Arthritis Care Res. 2014 Sept. 23 [doi:10.1002/acr.22482]).

Among black patients, longer wait times were not associated with graft failure in the adjusted analysis, and, in fact, there was a nonstatistically significant suggestion of a protective effect for wait time of 2 years or more. This finding may reflect unexplained differences in disease pathology between white and black LN-ESRD patients, the investigators said, adding that there was no increased risk of graft failure in black patients who were transplanted early.

“Our results suggest U.S. recommendations for transplantation in LN-ESRD may not align with evidence from the target population,” they said, noting that the results should be considered hypotheses-generating because of the limitations of the study and that additional study is needed to examine the potential confounding effects of clinically recognized SLE activity on the associations observed in this study.

Some of the investigators were supported through grants from the National Institutes of Health.

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

National Suicide Prevention Day fell on Sept. 10 this year, surrounded by National Suicide Prevention Week Sept. 8-14. The conversation, as I’m sure everyone noticed, was focused on the suicide of actor Robin Williams. As we move out a few weeks, my patients – especially those who have contemplated ending their own lives – continue to talk about this tragic loss.

The fear is that the suicide of a celebrity will lead to an increase in the suicide rate in the general public – copycat suicides, if you will. In the month after Marilyn Monroe died of an overdose in 1962, the suicide rate rose by more than 10%. On the other hand, the death of a celebrity may lead to a decrease in the suicide rate, as happened after Kurt Cobain’s death from a self-inflicted gunshot wound in 1994. In the period after Cobain’s death, an effort was made to publicize resources for those who need help. The suicide rate dropped, while calls to hotlines rose.

After Robin Williams’ death, my own social media feeds were full of ads for the National Suicide Prevention Lifeline (NSPL), a hotline with the number 1-800-273-TALK. There are other hotlines, but this was the one I saw most. I wanted to learn about suicide hotlines, so I did a few things: I asked readers of our Shrink Rap blog to tell me about their experiences, and I called the hotline myself to see if I could learn about the structure of the organization, what resources they had to offer a distraught caller, and whether there had been a change in the number of calls they’d received in the time following Mr. Williams’ death.

I called from my cell phone, which is registered in Maryland, while sitting in my home in Baltimore City. The call was routed to Grassroots Crisis Intervention Center in Columbia, Md. Google Maps tells me the center is 25 miles from my house, and it would take me 32 minutes to drive there. In addition to being part of a network of 160 hotline centers across the country, Grassroots has a walk-in crisis center and a mobile treatment center, and is adjacent to a homeless shelter.

“Most of the people who call the National Suicide Prevention Lifeline are suicidal,” said Nicole DeChirico, director of crisis intervention services for Grassroots. “There is a gradation in suicidal thinking, but about 90% of our callers are considering it.”

“We first form rapport, and then we try to quickly assess if an attempt has already been made, and if they are in any danger. We use the assessment of suicidality that is put out by the NSPL. It’s a structured template that is used as a guideline.”

Ms. DeChirico noted that the people who man the hotlines have bachelor’s or master’s degrees – often in psychology, social work, counseling, or education. If feasible, a Safety Planning Intervention is implemented, based on the work of Barbara Stanley, Ph.D., at Columbia University in New York.

“We talk to people about what they need to do to feel safe. If they allow it, we set up a follow-up call. Of the total number of people who have attempted suicide once in the past and lived, 90%-96% never go on to attempt suicide again,” Ms. DeChirico noted. Suicide is a time-limited acute crisis.”

The Grassroots team can see patients on site while they wait for appointments with an outpatient clinician, and can send a mobile crisis team to those who need it if they are in the county served by the organization. I wondered if all 160 agencies that received calls from the NSPL could also provide crisis services.

Marcia Epstein, LMSW, was director of the Headquarters Counseling Center in Lawrence, Kan., from 1979 to 2013. The center became part of the first national suicide prevention hotline network, the National Hopeline Network, 1-800-SUICIDE, in 2001, and then became part of the National Suicide Prevention Lifeline, 1-800-274-TALK (8255), when that network began in January 2005.

“The types of programs and agencies which are part of NSPL vary greatly. The accreditation that allows them to be part of the NSPL network also varies. Some centers are staffed totally by licensed mental health therapists, while others might include trained volunteers and paid counselors who have no professional degree or licensure. Service may be delivered by phone, as well as in person, by text, and by live chat. In person might be on site or through mobile crisis outreach. Some centers are part of other organizations, while others are free-standing, and some serve entire states, while others serve geographically smaller regions,” Ms. Epstein explained in a series of e-mails. She noted that some centers assess and refer, while others, like Grassroots, are able to provide more counseling.

“So if it sounds like I’m saying there is little consistency between centers, yes, that is my experience. But the centers all bring strong commitment to preventing suicide.”

Ms. Epstein continued to discuss the power of the work done with hotline callers.

“The really helpful counseling comes from the heart, from connecting to people with caring and respect and patience, and using our skills in helping them stay safer through the crisis and then, when needed, to stay safer in the long run. It takes a lot of bravery from the people letting us help. And it takes a lot of creativity and flexibility in coming up together with realistic plans to support safety.”

I was curious about the patient response, and I found that was mixed. It was also notable that different patients found different forms of communication to be helpful.

A woman who identified herself only as “Virginia Woolf” wrote, “I have contacted the Samaritans on the [email protected] line because I could write to them via e-mail. I don’t like phones and I also know too many of the counselors on the local crisis line. Each time I was definitely close to suicide. I was in despair and I had the means at hand. I think what stopped me was knowing they would reply. They always did, within a few hours, but waiting for their reply kept me safe.”

Not every response was as positive.

One writer noted, “It was not a productive, supportive, or empathetic person. I felt like she was arrogant, judgmental, and didn’t really care about why I was calling.” The same writer, however, was able to find solace elsewhere. “I have texted CrisisChat and it was an excellent chat and I did feel better.”

Finally, Ms. DeChirico sent me information about the call volume from our local NPSL center in Columbia. From July 1, 2013, to July 31, 2014, the Lifeline received an average of 134 calls per month. December had the highest number of calls, with 163, while August had the lowest with 118. September, February, and April all had 120 calls or fewer.

Robin Williams died on Aug. 11, 2014, and the center received 200 calls in August – a 49% increase over the average volume. Hopefully, we’ll end up seeing a decline in suicide in the months following Mr. Williams’ tragic death.

Dr. Miller is a coauthor of “Shrink Rap: Three Psychiatrists Explain Their Work” (Baltimore: Johns Hopkins University Press, 2011).

Three generations

of women in a family

By studying 3 generations of a family plagued by blood disorders, researchers discovered a genetic mutation that causes aplastic anemia.

The team performed whole-exome sequencing on DNA from the families and identified an inherited mutation on the ACD gene, which codes for the telomere-binding protein TPP1.

The mutation disrupts the interactions between telomeres and telomerase, which causes blood cells to die and results in aplastic anemia.

“Identifying this causal defect may help suggest future molecular-based treatments that bypass the gene defect and restore blood cell production,” said Hakon Hakonarson, MD, PhD, of The Children’s Hospital of Philadelphia in Pennsylvania.

Dr Hakonarson and his colleagues described this research in Blood.

The team studied an Australian family with aplastic anemia and other hematopoietic disorders, including leukemia. Whole-exome sequencing of the family’s DNA revealed an inherited mutation on the ACD gene.

The mutation is an amino acid deletion in the TEL patch of TPP1 (ΔK170). All of the family members with this mutation had short telomeres, and those with wild-type TPP1 did not.

The researchers introduced TPP1 with the ΔK170 mutation into 293T cells and found the protein could localize to telomeres but failed to recruit telomerase. The team said this indicates a causal relationship between the mutation and bone marrow disorders.

Without access to telomerase to help maintain telomeres, blood cells lose their structural integrity and die, resulting in bone marrow failure and aplastic anemia.

Nine other genes were previously found to play a role in bone marrow failure disorders. The current study adds ACD to the list and is the first time the gene has been shown to have a disease-causing role.

“This improved understanding of the underlying molecular mechanisms may suggest new approaches to treating disorders such as aplastic anemia,” Dr Hakonarson said. “For instance, investigators may identify other avenues for recruiting telomerase to telomeres to restore its protective function.”

Three generations

of women in a family

By studying 3 generations of a family plagued by blood disorders, researchers discovered a genetic mutation that causes aplastic anemia.

The team performed whole-exome sequencing on DNA from the families and identified an inherited mutation on the ACD gene, which codes for the telomere-binding protein TPP1.

The mutation disrupts the interactions between telomeres and telomerase, which causes blood cells to die and results in aplastic anemia.

“Identifying this causal defect may help suggest future molecular-based treatments that bypass the gene defect and restore blood cell production,” said Hakon Hakonarson, MD, PhD, of The Children’s Hospital of Philadelphia in Pennsylvania.

Dr Hakonarson and his colleagues described this research in Blood.

The team studied an Australian family with aplastic anemia and other hematopoietic disorders, including leukemia. Whole-exome sequencing of the family’s DNA revealed an inherited mutation on the ACD gene.

The mutation is an amino acid deletion in the TEL patch of TPP1 (ΔK170). All of the family members with this mutation had short telomeres, and those with wild-type TPP1 did not.

The researchers introduced TPP1 with the ΔK170 mutation into 293T cells and found the protein could localize to telomeres but failed to recruit telomerase. The team said this indicates a causal relationship between the mutation and bone marrow disorders.

Without access to telomerase to help maintain telomeres, blood cells lose their structural integrity and die, resulting in bone marrow failure and aplastic anemia.

Nine other genes were previously found to play a role in bone marrow failure disorders. The current study adds ACD to the list and is the first time the gene has been shown to have a disease-causing role.

“This improved understanding of the underlying molecular mechanisms may suggest new approaches to treating disorders such as aplastic anemia,” Dr Hakonarson said. “For instance, investigators may identify other avenues for recruiting telomerase to telomeres to restore its protective function.”

Three generations

of women in a family

By studying 3 generations of a family plagued by blood disorders, researchers discovered a genetic mutation that causes aplastic anemia.

The team performed whole-exome sequencing on DNA from the families and identified an inherited mutation on the ACD gene, which codes for the telomere-binding protein TPP1.

The mutation disrupts the interactions between telomeres and telomerase, which causes blood cells to die and results in aplastic anemia.

“Identifying this causal defect may help suggest future molecular-based treatments that bypass the gene defect and restore blood cell production,” said Hakon Hakonarson, MD, PhD, of The Children’s Hospital of Philadelphia in Pennsylvania.

Dr Hakonarson and his colleagues described this research in Blood.

The team studied an Australian family with aplastic anemia and other hematopoietic disorders, including leukemia. Whole-exome sequencing of the family’s DNA revealed an inherited mutation on the ACD gene.

The mutation is an amino acid deletion in the TEL patch of TPP1 (ΔK170). All of the family members with this mutation had short telomeres, and those with wild-type TPP1 did not.

The researchers introduced TPP1 with the ΔK170 mutation into 293T cells and found the protein could localize to telomeres but failed to recruit telomerase. The team said this indicates a causal relationship between the mutation and bone marrow disorders.

Without access to telomerase to help maintain telomeres, blood cells lose their structural integrity and die, resulting in bone marrow failure and aplastic anemia.

Nine other genes were previously found to play a role in bone marrow failure disorders. The current study adds ACD to the list and is the first time the gene has been shown to have a disease-causing role.

“This improved understanding of the underlying molecular mechanisms may suggest new approaches to treating disorders such as aplastic anemia,” Dr Hakonarson said. “For instance, investigators may identify other avenues for recruiting telomerase to telomeres to restore its protective function.”