Bipolar Disorder

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Comprehensive psychosocial interventions plus pharmacotherapy can bring improved symptoms in medically adherent patients with refractory bipolar disorder I or II for 5 years, a randomized study of 40 participants shows.

"As far as we know, this is the first study to show such long-term maintained efficacy," wrote Ana González-Isasi, Psy.D., a clinical psychologist affiliated with the psychiatry department at Hospital Universitario Insular, Las Palmas de Gran Canaria, Spain, and her colleagues.

The findings came after an earlier study based on the same data set led by Dr. González-Isasi found that combined therapy, fewer hospitalizations, and higher self-esteem were the key factors for favorable progression of bipolar disorder (Compr. Psychiatry 2012;53:224-9).

In the current study, the investigators looked at patients with refractory bipolar I or II who were receiving treatment at a mental health center in Las Palmas. The mean age of the patients was 41.3 years. Most were taking a combination of lithium salts and atypical antipsychotics, and others were on other medical regimens. Excluded from the study were patients with poor medication adherence and those with current manic, hypomanic, or depressive episodes as defined by the DSM-IV-TR (Eur. Psychiatry 2014;29:134-41).

Participants were randomized into two groups. In one group, the participants remained on drug therapy only, and each person met with a psychiatrist once a month. Participants in the experimental group also continued on medication, but also visited with a psychiatrist monthly and participated in a psychosocial intervention consisting of several components. The intervention included cognitive-behavioral therapy sessions, in which patients met with a psychologist assisted by psychiatric nurses in 20 weekly sessions that lasted 90 minutes, and underwent psychotherapy in groups of 10.

The investigators were able to establish adherence by persistently tracking each patient, Dr. González-Isasi said in an interview. "If someone didn’t come a day, I called him, asked what happened, and invited the patient to come the next day," she said.

Finally, the patients in the experimental group were taught about bipolar disorder and trained in the use of "anxiety-control techniques (relaxation and breathing, self-instructions and cognitive distraction), sleep hygiene habits, and planning gratifying activities. Later on, they were trained in detecting distorted thoughts and using the process of cognitive restructuring." Participants also learned about problem solving and techniques aimed at building self-esteem.

Among patients in the experimental group, no significant differences were found in the number of hospitalizations, but for those in the control group, the number of hospitalizations rose significantly (P = .018). Similar patterns were found in symptoms of anxiety and depression, based on the Beck Depression Inventory (P less than .001). For those in the experimental group, mania symptoms, based on scores on the Young Mania Rating Scale, remained unchanged (P = .093), and for those in the control group, mania symptoms increased significantly (P = .003).

It would helpful to know about the status of the subjects between the 12-month and 5-year assessments, the investigators said, citing the absence of this information as a limitation of the study. This knowledge would help illuminate the "trajectory of the clinical course of the illness," they wrote. "Further research should take this limitation into account."

Dr. González-Isasi and her coauthors declared that they had no conflicts of interest.

Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.

Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).

The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.

For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.

The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.

No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).

The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."

Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."

The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.

[email protected]

Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.

Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).

The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.

For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.

The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.

No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).

The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."

Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."

The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.

[email protected]

Affect Intensity Measure subscale scores can be used to help understand the complexity of emotions experienced by patients with bipolar disorder I and II, a study of 310 outpatients suggests.

Furthermore, four factors – positive affectivity, "unpeacefulness" (lack of serenity), negative reactivity, and negative intensity – allow clinicians to "explore more subtle components characterizing various aspects of emotional response" among patients with both types of bipolar, Flavie Mathieu, Ph.D., Dr. Bruno Etain, and their colleagues reported (J. Affect. Disord. 2014;157:8-13).

The Affect Intensity Measure (AIM) is a 40-item questionnaire designed to measure the extent to which patients experience emotion.

For the study, Dr. Mathieu, Dr. Etain, and their colleagues recruited patients at four university-affiliated psychiatric departments in France. All of the patients included in the study were aged 18 years or older (mean age, 42.4 years). In all, 233 of the patients met the DSM-IV criteria for bipolar disorder I, 65 met the criteria for bipolar II, and 12 for bipolar not otherwise specified, wrote Dr. Mathieu of Université Paris Diderot, Dr. Etain of Hôpital Albert Chenevier, Créteil, France, and their colleagues.

The team developed a French translation of the AIM and got it "backtranslated" by an independent translator. The patients were asked to describe their affect during euthymic periods rather than during either manic or depressive episodes. Euthymic states were confirmed based on the patients’ scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Mania Rating Scale.

No statistically significant association was found between the patients’ total AIM scores and the clinical characteristics of bipolar disorder. However, when the investigators looked at the four factors, they found significant associations between the AIM subscale scores and bipolar disorder characteristics. For example, the unpeacefulness subscale score was associated with the onset of psychotic symptoms (P = .0006) and substance misuse (P = .008). The negative intensity subscale score was associated with social phobia (P = .0005).

The investigators cited several limitations. For example, they found no correlation between the patients’ total AIM scores and MADRS scores, which suggests that "AIM total score is not necessarily influenced by depression."

Despite these limitations, the investigators said their findings "suggest that assessment of affective intensity using this self-report scale may be useful in clinical settings but also as a means of further characterizing [bipolar disorder] phenotypes in future research."

The research was funded by INSERM, Assistance Publique des Hôpitaux de Paris, Agence National pour la Recherche, and the Fondation FondaMental. The authors reported no financial conflicts.

[email protected]

Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.

Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.

HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).

Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.

The group’s other recommendations include:

• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.

• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.

• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.

• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.

One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.

[email protected]

On Twitter @alz_gal

Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.

Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.

HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).

Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.

The group’s other recommendations include:

• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.

• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.

• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.

• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.

One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.

[email protected]

On Twitter @alz_gal

Genetic testing for alleles that affect histocompatibility should be the rule for patients who initiate the drug carbamazepine, according to new recommendations issued by the Canadian Pharmacogenomics Network for Drug Safety.

Two variants are associated with the severe, sometimes deadly, skin reactions that carbamazepine can bring on, usually within the first 3 months of therapy. One (HLA-B*15-02) is a particularly high-risk allele that is not uncommon in patients of Chinese, Thai, Malaysian, and Indian descent. It’s strongly associated with Stevens-Johnson syndrome and toxic epidermal necrolysis in those taking carbamazepine.

HLA-A*31:01 has been found among white, Japanese, Korean, and Chinese patients; in fact, it is somewhat common in most ethnic groups and people of mixed descent. This allele is associated with Stevens-Johnson, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis, as well as some of the less-severe skin reactions, said Dr. Ursula Amstutz of the University of British Columbia, Vancouver, and her colleagues in the Network’s clinical recommendation group (Epilepsia 2014 March 5 [doi:10.1111/epi.12564]).

Genetic testing for the variants should be carried out before initiating treatment or within the first 3 months of treatment. But patients who have not had a reaction after at least 3 months’ treatment don’t need to be screened, advised the group, which used a systematic review of the literature to develop an expert consensus on the recommendations.

The group’s other recommendations include:

• Testing for HLA-B*15-02 should be done in all patients of the susceptible ethnic groups before treatment begins. It’s optional in groups where it is uncommon, but all drug-naïve patients should probably undergo the test.

• All patients, regardless of ethnicity, should undergo testing for HLA-A*31:01.

• Genetic testing should be done in patients who have previously experienced a skin reaction while taking carbamazepine, regardless of how long they have taken it.

• Negative tests don’t entirely rule out the possibility of a reaction, so patients, families, and physicians should still be alert for any early signs that one could develop.

One author was been a paid consultant for Novartis in legal cases relevant to carbamazepine-induced hypersensitivity. The others reported no relevant financial conflicts.

[email protected]

On Twitter @alz_gal

Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.

A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.

The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.

"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.

Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).

Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.

[email protected]

Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.

A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.

The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.

"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.

Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).

Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.

[email protected]

Different lots of brand-name and generic versions of extended-release venlafaxine are being recalled because of a report that one bottle contained a capsule of the antiarrhythmic drug dofetilide, according to the Food and Drug Administration.

A statement posted March 7 on the agency’s MedWatch site said that Pfizer has issued a voluntary recall of one lot of 30-count venlafaxine 150-mg extended-release capsules (marketed as Effexor XR), one lot of 90-count Effexor XR 150-mg capsules, and one lot of 90-count Greenstone LLC brand of venlafaxine 150-mg extended release capsules.

The recall was spurred by a pharmacist’s report that a 0.25-mg capsule of dofetilide (Tikosyn) was found in a bottle of Effexor XR.

"The use of Tikosyn by an Effexor XR/Venlafaxine HCl patient, where the contraindications and drug-drug interactions with Tikosyn have not been considered by the prescribing physician, could cause serious adverse health consequences that could be fatal," the notice said.

Tikosyn, also manufactured by Pfizer, is a class III antiarrhythmic drug that is approved for treating atrial fibrillation/atrial flutter. The drug’s label includes a black box warning that recommends patients start treatment in a facility where they can be closely monitored, to minimize the risk of a dofetilide-induced arrhythmia. There is also a Risk Evaluation and Mitigation Strategy (REMS) in place that addresses this risk. The affected venlafaxine XR products are Pfizer lot numbers V130142 and V130140, which both expire in October 2015; and Greenstone lot number V130014, which expires in August 2015. Patients who have the affected product are being advised to call their physicians and/or return the product to their pharmacies. The FDA advises patients with questions to call Stericycle at 888-345-0481 (Mon.-Fri., 8 a.m. to 5 p.m., Eastern time); or Pfizer, at 800-438-1985 (Mon.-Thur., 9 a.m. to 8 p.m., Eastern time or Fri., 9 a.m. to 5 p.m., Eastern time).

Adverse events associated with the use of these products should be reported to MedWatch at or 800-332-1088.

[email protected]

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A growing body of evidence suggests that a high proportion of men with hypersexual disorder have an axis I psychiatric comorbidity such as attention-deficit/hyperactivity disorder, an association that can easily fly under a clinician’s radar.

"ADHD is very prominent in men with hypersexual disorder who come to see me now, occurring about 45% of the time," Dr. Martin Kafka said at the annual psychopharmacology update held by the Nevada Psychiatric Association. "I spend half of my time trying to get authorizations for them to be prescribed stimulants."

Men with ADHD tend to "look for something novel when they’re feeling dysphoric affect like boredom or when they’re depressed," continued Dr. Kafka, clinical associate professor of psychiatry at Harvard Medical School, Boston, and an authority on hypersexual disorder (HD). "They procrastinate, so when they’re facing stressful events they escape through their sexual behavior. Pornography is very tempting, because it can be viewed with just the click of a button."

He based his remarks on an analysis of medical records from about 150 HD patients he’s treated in recent years, with a goal of expanding that data set to at least 300. Previous studies he published from 1994 to 2002 suggested that the association between HD and ADHD ranged from 17% to 19%. Those studies also found that dysthymia was the most common coexisting axis I disorder in HD patients, occurring 61%-62% of the time, followed by alcohol abuse (25%-39%) and social phobia (22%-25%).

In Dr. Kafka’s current clinical practice, about 26% of men with HD that he counsels also have bipolar spectrum disorder. "What’s interesting is that this tends to occur in patients with cyclothymic disorder or bipolar disorder not otherwise specified," he said. "It’s the ones who have hypomanias lasting 1-2 days, but repetitively, who have a family history of the illness. In community samples, about 5% of the population meets criteria for hypomania if you shorten the duration to 1-2 days. We really need to be sensitive about brief, recurrent hypomanias and things like cyclothymic disorder, where you’re not depressed for that long."

Though one hallmark symptom of major depressive disorder (MDD) is decreased sexual interest, a small body of literature suggests that the opposite might be true. "This sounds counterintuitive, but subgroups of patients with MDD can have increased sexual behavior," Dr. Kafka said. "Some can have chronically increased sexual behavior." In one 1993 study of cognitive therapy in 40 subjects who were having problems with sexual arousal, 28 got better. The 12 who didn’t get better had chronic low-grade depression" (Arch. Gen. Psychiatry 1993;50:24-30).

Other investigators have reported that when men are depressed, they are more likely to respond to dysphoric affect through action and impulsivity (Arch. Sexual Behav. 2003; 32:217-30). "So even though it’s counterintuitive, depressive disorders can be associated with hypersexuality," Dr. Kafka said.

Treatment of axis I disorders, when executed properly, can positively affect outcomes for patients with HD. "Consider doing a thorough diagnostic evaluation," Dr. Kafka advised. "If they’re not getting better with nonpharmacological treatments, or their behavior is endangering them, then medications could be indicated." He went on to note that the medical model "goes a long way to destigmatize behavior in patients with HD. Yes, there are people who do immoral acts. Promiscuous behavior is an immoral act. But it could be embedded in a psychiatric disorder, which makes it much more complex. It makes it much more understandable; it can destigmatize the person. The person is not just a philanderer; the person is somebody who has an affliction, whose symptom is philandering. They will connect with you if you say this is a medical psychiatric disorder and not just a moral issue."

Though no controlled studies exist on treatment strategies for HD, Dr. Kafka recommended integrating psychiatric diagnosis into the treatment of HD. He also recommended proactive communication with other mental health professionals in helping derive "a good diagnostic picture" of certain patients and educating them about subthreshold adult manifestations of psychiatric diagnoses. "Of course, they can’t really help you with identifying bipolar spectrum disorder or ADHD unless they’re educated about it, but it’s helpful when a psychotherapist tells you that a patient looked hypomanic to him," Dr. Kafka explained. "The next time you see that patient, you might want to ask about that."

He also recommended educating HD patients as much as possible about their illness from resources such as the Society for the Advancement of Sexual Health (www.sash.net) "because these are chronic, early-onset disorders. They’re going to have them for the rest of their lives. Unless they understand them, they’re going to use medication inappropriately, they’re not going to be as treatment compliant and collaborative, and they’re going to relapse."

As to treatment approaches for HD itself, Dr. Kafka recommended a "here and now" approach that involves external interventions to limit access to computers and smart phones, such as phone block, Internet filters with kept passwords, moving the computer to a more public location, changing Internet service providers, and removing credit cards. He acknowledged that disclosing HD to an unsuspecting spouse can be "a minefield. Unless a spouse is prepared to find out about this, it’s devastating, because this is a secret disorder. Many times the spouse has no clue. I’m not going to say don’t tell the spouse, I’m going to say be very careful with your patient about what might be a strategy and when a spouse should find out. When the spouse finds out, it’s important that the spouse be in treatment, that they know how to get some help."

Frequent 12-step meetings that include daily contact with a sponsor are typically indicated for patients with HD, he added, along with individual psychotherapy and some cognitive-behavioral therapy.

"Hypersexuality is a dimension of human behavior; it can be treated," Dr. Kafka concluded. "The psychiatrist is an important player in all this."

Dr. Kafka said that he had no relevant financial conflicts to disclose.

[email protected]

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

Overgeneral autobiographical memory – an alteration in the specificity of memory from an individual’s life – is a characteristic of bipolar I disorder and relates to executive function, according to a report published in Comprehensive Psychiatry.

"We found a greater prevalence of overgeneralized [autobiographical memory] in [bipolar disorder] patients compared to healthy controls," wrote lead study author Woo Jung Kim of Yonsei University in Seoul, South Korea, and his associates. "Our results suggest [autobiographical memory] may be a characteristic of [bipolar disorder] along with certain cognitive functions."

The investigators recruited 28 bipolar I disorder patients from inpatient and outpatient clinics at Severance Mental Health Hospital, and 28 healthy age- and sex-matched controls. The patients were between the ages of 20 and 50.The researchers gave all participants the autobiographical memory test (AMT), a word-cuing technique aimed at assessing the degree of specificity of autobiographical memory, and a 2-hour neuropsychological battery to assess general intelligence, attention, verbal memory, verbal fluency, visual memory, and executive functions.

The AMT was adapted to Korean culture, using five positive adjectives (happy, successful, safe, interested, and loved) and five negative adjectives (hurtful, angry, lonely, failed, and dangerous). The words were written on paper cards and shown to participants one at a time, while those administering the test encouraged participants to recall specific memories and describe them in as much detail as possible within 1 minute each.

Each patient was interviewed using the Mini-International Neuropsychiatric Interview. Their residual mania symptoms were assessed using the Young Mania Rating Scale, and their depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale. Patients with other medical or psychiatric comorbidities were excluded, as were those with mental retardation or a history of head trauma (Compr. Psychiatry 2014;55:290-7).

The investigators found the total and negative AMT scores to be significantly lower in the patients with bipolar disorder than in healthy controls. For example, among the patients with bipolar disorder, the total autobiographical memory test scores were 3.86 plus or minus 2.85, compared with 5.32 plus or minus 2.57 among the healthy controls. Meanwhile, the negative autobiographical memory test scores were 1.86 plus or minus 1.38 among the patients with bipolar disorder and 2.75 plus or minus 1.40 among the healthy controls.

In addition, the patients with bipolar disorder "tended to report more general and fewer specific positive memories than did the healthy controls, although the difference was not statistically significant." The bipolar disorder group had significantly lower verbal memory, verbal fluency, and visual memory test scores than the healthy controls, but the results of tests for executive function were not different between the groups.

In bipolar disorder patients, the AMT scores correlated significantly with intelligence and perseverative errors. In healthy controls, they correlated with verbal memory and fluency.

The investigators cited several limitations. The sample size was fairly small, but it was similar to that of previous studies of autobiographical memory and bipolar disorder, they said. None of the patients in the study had psychotic symptoms at the time of enrollment, but the investigators did not access the patients’ prior history of such symptoms.

"Future research should investigate the specific [autobiographical memory] neural network in [bipolar disorder] individuals and examine the relationship between [autobiographical memory] and psychosocial functions and quality of life," the authors wrote. This may provide insight into the benefit of additional treatment focusing on overgeneral autobiographical memory in bipolar disorder, they said.

This study was supported by the Korea Healthcare Technology R&D Project of the Ministry of Health & Welfare of the Republic of Korea. The authors reported no relevant financial disclosures.

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Statewide health care reform in Massachusetts did not increase inpatient admissions for behavioral diagnoses among adolescents and young adults, as some had feared. Instead, reform led to a decrease in such admissions, a report published online Feb. 19 in JAMA Psychiatry showed.

This suggests nationwide health care reform might have a similar effect, at least in states that, like Massachusetts, offer robust hospital-based mental health services.

©AndreyPopov/thinkstockphotos.com

One major goal of health care reform is to extend insurance coverage to populations least likely to have it, such as young adults. Given that most behavioral health disorders emerge in adolescence and young adulthood, some experts were concerned that newly acquired insurance coverage for this age group might lead to increases in hospital and emergency department admissions for behavioral issues, said Ellen Meara, Ph.D., of the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., and her associates.

To assess whether the enactment of national health care reform might lead to a sharp increase in such hospital and ED admissions, the investigators examined the experience in Massachusetts after statewide health care reform was enacted there in 2006.

They analyzed the records of 2,533,307 admissions for any diagnosis and 6,817,855 ED visits for any diagnosis and focused on young adults aged 19-25 years – "a group with relatively high behavioral health needs and low rates of insurance coverage prior to reform" (JAMA Psychiatry 2014 Feb. 19 [doi:10.1001/jamapsychiatry.2013.3972]).

Dr. Meara and her associates found that the uninsured rate fell from 26% to 10% among this population after health reform. The increase in insurance coverage was accompanied by a decline in patient admission rates and ED visits for young adults with behavioral health diagnoses. The drop was fueled primarily by a decrease in admissions and ED visits for substance use disorders. This pattern suggests that most of these patients are being redirected – appropriately – to outpatient services, Dr. Meara and her associates said.

The findings are reassuring in that they appear to show that young people with behavioral health issues will now find the care they need to be more accessible and affordable, without increasing the burden on hospitals or raising inpatient costs, they said.

Dr. Meara and her associates cited a few limitations. For example, outpatient treatment for mental illness or substance use disorders was not observed. "Thus, we cannot infer whether use of hospital-based care for mental illness and substance use disorders represents lower rates of morbidity in the population, effective care in outpatient settings, or restrictions on use of hospital-based settings," they wrote. In addition, they did not look at admissions to psychiatric or alcohol or chemical-dependency facilities.

Still, the data "offer a snapshot of one aspect of policies to improve access to behavioral health treatment, expanded insurance coverage," they said.

The study was supported by the National Institutes of Health and the National Institute of Drug Abuse. No financial conflicts of interest were reported.

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

[email protected]

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

[email protected]

Whole brain tractography imaging shows decreased white matter integrity in patients with bipolar I disorder, compared with individuals without the disorder, a study published online in JAMA Psychiatry shows.

This effect was even more pronounced in bipolar patients with a history of psychotic features, defined as the patient having had at least one manic or depressive episode with delusions or hallucinations, wrote Samuel Sarrazin and his colleagues.

The investigators compared generalized fractional anisotropy (GFA) values in 118 bipolar I patients recruited from multiple university-affiliated centers in France, Germany, and the United States, with a control group of 86 participants who had no personal or family history of Axis I mood disorders, schizophrenia, or schizoaffective disorder. A lower GFA value suggests loss of integrity or coherence of white matter, the authors said.

At all of the sites, the Montgomery-Åsberg Depression Rating Scale or the Hamilton Depression Rating Scale were administered, in addition to the Young Mania Rating Scale, and the National Adult Reading Test, reported Mr. Sarrazin, who is affiliated with several French medical institutions, including the Assistance Publique–Hôpitaux de Paris.

The mean age of disease onset among the patients with bipolar I was about 20.8 years, and the mean age at MRI was about 36.3 years. For the healthy controls, the mean age at MRI was 37.2 years (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4513]).

In a linear mixed-model analysis comparing the two groups, patients with bipolar I disorder had an average GFA value of 0.101 in the body of the corpus callosum, 0.113 in the splenium, and 0.079 in the anterior segment of the left hemisphere, compared with values of 0.102, 0.115, and 0.081, respectively, in the control group. Results remained significant when adjusting for false discovery rate (P = .03), and were consistent when researchers removed patients from the sample who had confounding factors such as elevated or mixed symptoms, the taking of lithium, and the existence of past alcohol abuse.

Bipolar I patients with a history of psychotic features had even lower GFA values than did bipolar patients with no psychotic history, with a mean GFA value of 0.100 in the body of the corpus callosum. This difference remained significant after adjusting for false discovery rate (P = .03).

"These results highlight the role of interhemispheric disconnectivity" in bipolar I disorder and suggest that bipolar I disorder with psychotic features "could be a relevant subtype of bipolar disorder with specific pathophysiological features," the investigators wrote. Additional large, multicenter studies are needed to compare bipolar I disorder with other psychotic disorders, and to further study such neuroimaging biomarkers, they added.

In an accompanying editorial, Dr. Kathryn R. Cullen and Dr. Kelvin O. Lim said that the latest findings advance the diffusion imaging literature in that the sample was large enough to address two important questions: "where [white matter] deficits are most consistent and how abnormalities vary across subtypes of [bipolar disorder]."

Furthermore, they said, the findings "conclusively affirm prior reports suggesting impaired [fractional anisotropy] in [white matter] tracts ... using state-of-the-art methods. Exciting contributions are the documentation of a more severe biological abnormality in the subgroup of patients with psychosis and additional evidence supporting an interhemispheric disconnectivity theory in [bipolar disorder]," wrote Dr. Cullen and Dr. Lim, both of the University of Minnesota, Minneapolis (JAMA Psychiatry 2014 Feb. 12 [doi:10.1001/jamapsychiatry.2013.4638]).

Mr. Sarrazin and his colleagues cited several limitations to their study. First, they "did not explore the interrater and intersite reliability of the scales used in the study." Second, they did not include a "phantom procedure" to check the intercenter quality of the acquisitions. Third, the authors cannot exclude a possible effect of past medication use on the results. Fourth, given the large number of tracts to assess, the authors did not exploit other metrics from the orientation distribution function. Last, mean GFA values were calculated along each tract to perform comparisons, and localized decreases in GFA values might have gone undetected.

Neither Mr. Sarrazin nor his colleagues reported conflicts of interest. The study was funded by Alliance Nationale pour les Sciences de la Vie et de la Santé (aviesan), the Agence Nationale pour la Recherche, the Deutsche Forschungsgemeinschaft, the National Institute of Mental Health, and the Agence Régionale de Santé Ile-de-France.

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