Somatic Disorders

An estimated 1% of Americans have trichotillomania (TTM), an impulse-control disorder in which patients experience pleasure or gratification from recurrently pulling out their own hair, resulting in noticeable hair loss.^1,2 This disorder is more commonly diagnosed in women, likely reflecting treatment-seeking bias; women may be more likely to seek care for TTM because of social stigma associated with hair loss.² Avulsion of hair usually occurs at the scalp, but also can be seen in multiple sites, including eyebrows, eyelashes, beards, and pubic regions; the number of sites typically increases with the patient’s age.³

The lifetime prevalence of comorbid axis I disorders in patients with TTM is 82%.³ Because of this, TTM often is first encountered in a psychiatric setting. Psychiatrists should have knowledge of TTM diagnosis and treatment because they may be the only point of care for TTM patients. When considering a TTM diagnosis, be aware that in some cultures rending hair is a mourning ritual or a rite of passage.³

Evidence for cognitive therapies

Behavioral models suggest TTM behaviors are learned and maintained by both classical and operant conditioning. Therapies that target the cognitive processes that trigger urges to pull, the avulsion of hair, and recognizing the consequences have the best empirical support.³

Habit reversal training (HRT) is considered the most effective treatment for TTM.³ One trial found a single 2-hour HRT intervention resulted in greater reductions in hair pulling episodes and higher remission rates compared with placebo.³ HRT trains patients to create a competing response, such as fist clenching, that is incompatible and blocks the undesired response.

Other therapeutic approaches to TTM include acceptance and commitment therapy, cognitive-behavioral therapy (CBT), and dialectical behavioral therapy-enhanced HRT. Evidence is most robust for CBT-HRT; randomized controlled trials found a statistically significant reduction in TTM in patients receiving CBT-HRT.³ One review suggests CBT-HRT should be considered first-line therapy for TTM.³

Pharmacologic options

Although no medications are FDA-approved for treating TTM, options include clomipramine, olanzapine, fluoxetine, pimozide, inositol, naltrexone, and N-acetylcysteine.^2,3 The most robust trials of pharmacotherapy monotherapy were for N-acetylcysteine and naltrexone; both medications had significantly greater reduction in hair-pulling symptoms compared with placebo.³ Some evidence suggests combined pharmacotherapy and psychotherapy might be an effective approach.^2,3

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

An estimated 1% of Americans have trichotillomania (TTM), an impulse-control disorder in which patients experience pleasure or gratification from recurrently pulling out their own hair, resulting in noticeable hair loss.^1,2 This disorder is more commonly diagnosed in women, likely reflecting treatment-seeking bias; women may be more likely to seek care for TTM because of social stigma associated with hair loss.² Avulsion of hair usually occurs at the scalp, but also can be seen in multiple sites, including eyebrows, eyelashes, beards, and pubic regions; the number of sites typically increases with the patient’s age.³

The lifetime prevalence of comorbid axis I disorders in patients with TTM is 82%.³ Because of this, TTM often is first encountered in a psychiatric setting. Psychiatrists should have knowledge of TTM diagnosis and treatment because they may be the only point of care for TTM patients. When considering a TTM diagnosis, be aware that in some cultures rending hair is a mourning ritual or a rite of passage.³

Evidence for cognitive therapies

Behavioral models suggest TTM behaviors are learned and maintained by both classical and operant conditioning. Therapies that target the cognitive processes that trigger urges to pull, the avulsion of hair, and recognizing the consequences have the best empirical support.³

Habit reversal training (HRT) is considered the most effective treatment for TTM.³ One trial found a single 2-hour HRT intervention resulted in greater reductions in hair pulling episodes and higher remission rates compared with placebo.³ HRT trains patients to create a competing response, such as fist clenching, that is incompatible and blocks the undesired response.

Other therapeutic approaches to TTM include acceptance and commitment therapy, cognitive-behavioral therapy (CBT), and dialectical behavioral therapy-enhanced HRT. Evidence is most robust for CBT-HRT; randomized controlled trials found a statistically significant reduction in TTM in patients receiving CBT-HRT.³ One review suggests CBT-HRT should be considered first-line therapy for TTM.³

Pharmacologic options

Although no medications are FDA-approved for treating TTM, options include clomipramine, olanzapine, fluoxetine, pimozide, inositol, naltrexone, and N-acetylcysteine.^2,3 The most robust trials of pharmacotherapy monotherapy were for N-acetylcysteine and naltrexone; both medications had significantly greater reduction in hair-pulling symptoms compared with placebo.³ Some evidence suggests combined pharmacotherapy and psychotherapy might be an effective approach.^2,3

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

An estimated 1% of Americans have trichotillomania (TTM), an impulse-control disorder in which patients experience pleasure or gratification from recurrently pulling out their own hair, resulting in noticeable hair loss.^1,2 This disorder is more commonly diagnosed in women, likely reflecting treatment-seeking bias; women may be more likely to seek care for TTM because of social stigma associated with hair loss.² Avulsion of hair usually occurs at the scalp, but also can be seen in multiple sites, including eyebrows, eyelashes, beards, and pubic regions; the number of sites typically increases with the patient’s age.³

The lifetime prevalence of comorbid axis I disorders in patients with TTM is 82%.³ Because of this, TTM often is first encountered in a psychiatric setting. Psychiatrists should have knowledge of TTM diagnosis and treatment because they may be the only point of care for TTM patients. When considering a TTM diagnosis, be aware that in some cultures rending hair is a mourning ritual or a rite of passage.³

Evidence for cognitive therapies

Behavioral models suggest TTM behaviors are learned and maintained by both classical and operant conditioning. Therapies that target the cognitive processes that trigger urges to pull, the avulsion of hair, and recognizing the consequences have the best empirical support.³

Habit reversal training (HRT) is considered the most effective treatment for TTM.³ One trial found a single 2-hour HRT intervention resulted in greater reductions in hair pulling episodes and higher remission rates compared with placebo.³ HRT trains patients to create a competing response, such as fist clenching, that is incompatible and blocks the undesired response.

Other therapeutic approaches to TTM include acceptance and commitment therapy, cognitive-behavioral therapy (CBT), and dialectical behavioral therapy-enhanced HRT. Evidence is most robust for CBT-HRT; randomized controlled trials found a statistically significant reduction in TTM in patients receiving CBT-HRT.³ One review suggests CBT-HRT should be considered first-line therapy for TTM.³

Pharmacologic options

Although no medications are FDA-approved for treating TTM, options include clomipramine, olanzapine, fluoxetine, pimozide, inositol, naltrexone, and N-acetylcysteine.^2,3 The most robust trials of pharmacotherapy monotherapy were for N-acetylcysteine and naltrexone; both medications had significantly greater reduction in hair-pulling symptoms compared with placebo.³ Some evidence suggests combined pharmacotherapy and psychotherapy might be an effective approach.^2,3

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

NEW ORLEANS – An innovative group behavioral counseling intervention shows promise as a means of getting older sedentary knee osteoarthritis patients to stick with a beneficial physical activity program, a preliminary study has shown.

Supplementing a traditional exercise therapy intervention with group-mediated cognitive-behavioral counseling (GMCB) sessions resulted in knee osteoarthritis patients spending significantly more minutes per week engaged in moderate to vigorous physical activity than with the standard exercise intervention alone, Brian C. Focht, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

At least that was true following the 3-month intensive phase of the randomized, single-blind IMPACT-P (Improving Maintenance of Physical Activity–Pilot) trial. The real test of the durability of GMCB effectiveness will come later, at the prespecified 12-month follow-up. But Dr. Focht said he anticipates that the GMCB arm of the study will probably continue to show superior outcomes long term, as it has been his anecdotal impression that a substantial number of patients in the control arm returned to their sedentary ways fairly soon after the 3-month structured intervention ended.

And that, in a nutshell, has been the problem all along with exercise as therapy in patients with knee osteoarthritis, he added. Numerous studies have consistently shown that physical activity interventions result in clinically meaningful improvement in function and quality of life scores in older, sedentary patients with knee osteoarthritis. However, the long-term efficacy of these exercise interventions is often undermined by poor adherence to the physical activity regimen once the structured intervention is completed.

This observation was the impetus for the IMPACT-P trial. The hypothesis was that the targeted group counseling sessions would systematically instill in patients the self-regulatory skills required to consistently exercise on their own, explained Dr. Focht, an exercise scientist at Ohio State University, Columbus.

"To my mind, one of the unique elements of the GMCB intervention is that we’re trying to use the social dynamics of the group to develop commitment to the learning, practice, and implementation of the self-regulatory processes while also using peer-initiated solutions that come from those group sessions to overcome barriers that typically impede participation in physical activity," Dr. Focht explained.

The study included 80 sedentary knee osteoarthritis patients with an average age of 63. They were randomized to a standard exercise intervention or to exercise plus GMCB. Both interventions lasted for 3 months and included 36 hours of contact with health professionals. The exercise prescription was the same for both groups: 30-40 minutes of supervised moderate-intensity walking plus roughly 20 minutes of progressive lower-body strength training, with 8-12 repetitions of leg extensions, leg curls, step ups, and calf raises.

But while the control group had three supervised sessions per week in the gym for 3 months, the GMCB had two sessions per week during month 1 and one per week thereafter through month 4. This was followed by two sessions per month in months 5 and 6 and one monthly session during months 7 and 8. And after each supervised 1-hour exercise session, patients in the GMCB arm participated in a 20-minute group counseling session.

These cognitive-behavioral counseling sessions consisted of a standard package targeted at promoting self-monitoring of activity, effort, and symptoms; individual and group goal setting; social problem solving to overcome barriers to increasing physical activity; a mindfulness-based approach to pain management; and relapse-prevention strategies.

In keeping with a core tenet of cognitive-behavioral therapy, the GMCB intervention emphasized behavioral homework assignments. The goal, Dr. Focht noted, was to help patients phase in a reduced reliance on supervised, center-based exercise and an increase in independent physical activity.

The primary study end point was self-reported minutes per week of moderate to vigorous physical activity as assessed using the well-validated Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. From a baseline of about 225 minutes, the GMCB group increased their average level to more than 350 minutes at 3 months, while the control group showed no significant change over time.

"This would be categorized as a moderate effect size in terms of change in physical activity," according to Dr. Focht.

IMPACT-P was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Focht reported having no relevant financial conflicts.

NEW ORLEANS – An innovative group behavioral counseling intervention shows promise as a means of getting older sedentary knee osteoarthritis patients to stick with a beneficial physical activity program, a preliminary study has shown.

Supplementing a traditional exercise therapy intervention with group-mediated cognitive-behavioral counseling (GMCB) sessions resulted in knee osteoarthritis patients spending significantly more minutes per week engaged in moderate to vigorous physical activity than with the standard exercise intervention alone, Brian C. Focht, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

At least that was true following the 3-month intensive phase of the randomized, single-blind IMPACT-P (Improving Maintenance of Physical Activity–Pilot) trial. The real test of the durability of GMCB effectiveness will come later, at the prespecified 12-month follow-up. But Dr. Focht said he anticipates that the GMCB arm of the study will probably continue to show superior outcomes long term, as it has been his anecdotal impression that a substantial number of patients in the control arm returned to their sedentary ways fairly soon after the 3-month structured intervention ended.

And that, in a nutshell, has been the problem all along with exercise as therapy in patients with knee osteoarthritis, he added. Numerous studies have consistently shown that physical activity interventions result in clinically meaningful improvement in function and quality of life scores in older, sedentary patients with knee osteoarthritis. However, the long-term efficacy of these exercise interventions is often undermined by poor adherence to the physical activity regimen once the structured intervention is completed.

This observation was the impetus for the IMPACT-P trial. The hypothesis was that the targeted group counseling sessions would systematically instill in patients the self-regulatory skills required to consistently exercise on their own, explained Dr. Focht, an exercise scientist at Ohio State University, Columbus.

"To my mind, one of the unique elements of the GMCB intervention is that we’re trying to use the social dynamics of the group to develop commitment to the learning, practice, and implementation of the self-regulatory processes while also using peer-initiated solutions that come from those group sessions to overcome barriers that typically impede participation in physical activity," Dr. Focht explained.

The study included 80 sedentary knee osteoarthritis patients with an average age of 63. They were randomized to a standard exercise intervention or to exercise plus GMCB. Both interventions lasted for 3 months and included 36 hours of contact with health professionals. The exercise prescription was the same for both groups: 30-40 minutes of supervised moderate-intensity walking plus roughly 20 minutes of progressive lower-body strength training, with 8-12 repetitions of leg extensions, leg curls, step ups, and calf raises.

But while the control group had three supervised sessions per week in the gym for 3 months, the GMCB had two sessions per week during month 1 and one per week thereafter through month 4. This was followed by two sessions per month in months 5 and 6 and one monthly session during months 7 and 8. And after each supervised 1-hour exercise session, patients in the GMCB arm participated in a 20-minute group counseling session.

These cognitive-behavioral counseling sessions consisted of a standard package targeted at promoting self-monitoring of activity, effort, and symptoms; individual and group goal setting; social problem solving to overcome barriers to increasing physical activity; a mindfulness-based approach to pain management; and relapse-prevention strategies.

In keeping with a core tenet of cognitive-behavioral therapy, the GMCB intervention emphasized behavioral homework assignments. The goal, Dr. Focht noted, was to help patients phase in a reduced reliance on supervised, center-based exercise and an increase in independent physical activity.

The primary study end point was self-reported minutes per week of moderate to vigorous physical activity as assessed using the well-validated Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. From a baseline of about 225 minutes, the GMCB group increased their average level to more than 350 minutes at 3 months, while the control group showed no significant change over time.

"This would be categorized as a moderate effect size in terms of change in physical activity," according to Dr. Focht.

IMPACT-P was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Focht reported having no relevant financial conflicts.

NEW ORLEANS – An innovative group behavioral counseling intervention shows promise as a means of getting older sedentary knee osteoarthritis patients to stick with a beneficial physical activity program, a preliminary study has shown.

Supplementing a traditional exercise therapy intervention with group-mediated cognitive-behavioral counseling (GMCB) sessions resulted in knee osteoarthritis patients spending significantly more minutes per week engaged in moderate to vigorous physical activity than with the standard exercise intervention alone, Brian C. Focht, Ph.D., reported at the annual meeting of the Society of Behavioral Medicine.

At least that was true following the 3-month intensive phase of the randomized, single-blind IMPACT-P (Improving Maintenance of Physical Activity–Pilot) trial. The real test of the durability of GMCB effectiveness will come later, at the prespecified 12-month follow-up. But Dr. Focht said he anticipates that the GMCB arm of the study will probably continue to show superior outcomes long term, as it has been his anecdotal impression that a substantial number of patients in the control arm returned to their sedentary ways fairly soon after the 3-month structured intervention ended.

And that, in a nutshell, has been the problem all along with exercise as therapy in patients with knee osteoarthritis, he added. Numerous studies have consistently shown that physical activity interventions result in clinically meaningful improvement in function and quality of life scores in older, sedentary patients with knee osteoarthritis. However, the long-term efficacy of these exercise interventions is often undermined by poor adherence to the physical activity regimen once the structured intervention is completed.

This observation was the impetus for the IMPACT-P trial. The hypothesis was that the targeted group counseling sessions would systematically instill in patients the self-regulatory skills required to consistently exercise on their own, explained Dr. Focht, an exercise scientist at Ohio State University, Columbus.

"To my mind, one of the unique elements of the GMCB intervention is that we’re trying to use the social dynamics of the group to develop commitment to the learning, practice, and implementation of the self-regulatory processes while also using peer-initiated solutions that come from those group sessions to overcome barriers that typically impede participation in physical activity," Dr. Focht explained.

The study included 80 sedentary knee osteoarthritis patients with an average age of 63. They were randomized to a standard exercise intervention or to exercise plus GMCB. Both interventions lasted for 3 months and included 36 hours of contact with health professionals. The exercise prescription was the same for both groups: 30-40 minutes of supervised moderate-intensity walking plus roughly 20 minutes of progressive lower-body strength training, with 8-12 repetitions of leg extensions, leg curls, step ups, and calf raises.

But while the control group had three supervised sessions per week in the gym for 3 months, the GMCB had two sessions per week during month 1 and one per week thereafter through month 4. This was followed by two sessions per month in months 5 and 6 and one monthly session during months 7 and 8. And after each supervised 1-hour exercise session, patients in the GMCB arm participated in a 20-minute group counseling session.

These cognitive-behavioral counseling sessions consisted of a standard package targeted at promoting self-monitoring of activity, effort, and symptoms; individual and group goal setting; social problem solving to overcome barriers to increasing physical activity; a mindfulness-based approach to pain management; and relapse-prevention strategies.

In keeping with a core tenet of cognitive-behavioral therapy, the GMCB intervention emphasized behavioral homework assignments. The goal, Dr. Focht noted, was to help patients phase in a reduced reliance on supervised, center-based exercise and an increase in independent physical activity.

The primary study end point was self-reported minutes per week of moderate to vigorous physical activity as assessed using the well-validated Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire. From a baseline of about 225 minutes, the GMCB group increased their average level to more than 350 minutes at 3 months, while the control group showed no significant change over time.

"This would be categorized as a moderate effect size in terms of change in physical activity," according to Dr. Focht.

IMPACT-P was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Focht reported having no relevant financial conflicts.

MIAMI – Hispanic patients reported significantly higher rates of pain, numbness, cognition difficulties, vomiting, and severe sadness than non-Hispanics in a survey of 622 cancer patients awaiting appointments at three hospitals in the Bronx, New York City’s poorest borough.

"Hispanic patients consistently reported more emotional and practical complaints contributing to overall distress," Katie O'Callaghan reported at the annual meeting of the American Psychosocial Oncology Society.

"These are alarming results for us," she said.

Outpatients interviewed for the survey roughly reflected the demographics of the Bronx, a highly diverse, densely populated county where 5,000 new cancer cases are diagnosed each year. They were approached at Montefiore, Jacobi, and Lincoln hospitals.

With a mean age of 58 years (range, 18-100), the group included non-Hispanic whites (15%), African Americans (32%), and Hispanics (45%) with family origins in Mexico, the Caribbean, and South and Central America. Nearly three-quarters, 73%, were women. The most common cancers were breast (29%), gynecologic (14%), hematologic (10%), colorectal (9%), lung (7%), and prostate (3%).

Ms. O’Callaghan, research coordinator at Albert Einstein College of Medicine, New York, noted that among 256 Hispanics who completed the oral survey, 51% were Spanish-language dominant, reporting little or no English fluency. Communication barriers might be one explanation for the marked disparity in reports of physical symptoms, she suggested.

Indeed, on some measures, differences were seen between Hispanic patients who spoke English and those who did not. For example, 64% of Spanish-dominant Hispanics reported fatigue, compared with 49% of English-dominant Hispanic patients, a significant difference (P less than .05).

Spanish-dominant Hispanic patients also reported more practical problems (such as housing, transportation, and child care problems) as contributors to their distress (P less than .05).

But major differences persisted among the ethnic groups surveyed.

Overall, the same percentage – 49.5% – of Hispanic and white patients expressed clinically significant levels of distress – a composite measure that consists of 34 physical, practical, emotional, and spiritual/religious factors – compared with 42.5% of African Americans.

But 45% of Hispanic patients reported moderate to severe pain, more than twice the percentage of whites (20%) and substantially more than African Americans (37%). The differences among the three ethnic groups were significant (P less than .01).

Moderate to severe problems with cognition were reported by similar percentages of African Americans and whites (20% and 19%), but 31% of Hispanics, a difference significant at the P less than .05 level.

Sadness was reported as moderate to severe by 41% of Hispanics, and was significantly more distressful than in non-Hispanics in the survey (P less than .05). Again, about equal percentages of whites and African Americans reported great sadness (31% and 29%).

Divergence by ethnicity also was seen for moderate to severe numbness (reported by 39% of Hispanics, 30% of African Americans, and 20% of whites) and moderate to severe vomiting (reported by 13% of Hispanics and 8% of African Americans, but only 1% of whites).

"This psychological assessment study gives voice to the needs of Hispanic cancer patients who demonstrate greater distress and oncology symptoms [than other groups]," Ms. O’Callaghan said.

The silver lining in the study, she noted, was that Hispanic patients were also more likely than non-Hispanic patients, 26% vs. 21%, to be interested in receiving counseling for their emotional problems.

Coauthor Alyson B. Moadel, Ph.D., director of psychosocial oncology at the Albert Einstein Cancer Center, highlighted "a very big effort ... in terms of quality improvement," in part in response to the study findings.

One specific intervention is a volunteer companion program offering one-to-one support for cancer patients as they receive treatment for cancer, Dr. Moadel said, after Ms. O’Callaghan’s presentation at the meeting.

The study was funded by the Entertainment Industry Foundation; none of the authors reported any relevant financial disclosures.

MIAMI – Hispanic patients reported significantly higher rates of pain, numbness, cognition difficulties, vomiting, and severe sadness than non-Hispanics in a survey of 622 cancer patients awaiting appointments at three hospitals in the Bronx, New York City’s poorest borough.

"Hispanic patients consistently reported more emotional and practical complaints contributing to overall distress," Katie O'Callaghan reported at the annual meeting of the American Psychosocial Oncology Society.

"These are alarming results for us," she said.

Outpatients interviewed for the survey roughly reflected the demographics of the Bronx, a highly diverse, densely populated county where 5,000 new cancer cases are diagnosed each year. They were approached at Montefiore, Jacobi, and Lincoln hospitals.

With a mean age of 58 years (range, 18-100), the group included non-Hispanic whites (15%), African Americans (32%), and Hispanics (45%) with family origins in Mexico, the Caribbean, and South and Central America. Nearly three-quarters, 73%, were women. The most common cancers were breast (29%), gynecologic (14%), hematologic (10%), colorectal (9%), lung (7%), and prostate (3%).

Ms. O’Callaghan, research coordinator at Albert Einstein College of Medicine, New York, noted that among 256 Hispanics who completed the oral survey, 51% were Spanish-language dominant, reporting little or no English fluency. Communication barriers might be one explanation for the marked disparity in reports of physical symptoms, she suggested.

Indeed, on some measures, differences were seen between Hispanic patients who spoke English and those who did not. For example, 64% of Spanish-dominant Hispanics reported fatigue, compared with 49% of English-dominant Hispanic patients, a significant difference (P less than .05).

Spanish-dominant Hispanic patients also reported more practical problems (such as housing, transportation, and child care problems) as contributors to their distress (P less than .05).

But major differences persisted among the ethnic groups surveyed.

Overall, the same percentage – 49.5% – of Hispanic and white patients expressed clinically significant levels of distress – a composite measure that consists of 34 physical, practical, emotional, and spiritual/religious factors – compared with 42.5% of African Americans.

But 45% of Hispanic patients reported moderate to severe pain, more than twice the percentage of whites (20%) and substantially more than African Americans (37%). The differences among the three ethnic groups were significant (P less than .01).

Moderate to severe problems with cognition were reported by similar percentages of African Americans and whites (20% and 19%), but 31% of Hispanics, a difference significant at the P less than .05 level.

Sadness was reported as moderate to severe by 41% of Hispanics, and was significantly more distressful than in non-Hispanics in the survey (P less than .05). Again, about equal percentages of whites and African Americans reported great sadness (31% and 29%).

Divergence by ethnicity also was seen for moderate to severe numbness (reported by 39% of Hispanics, 30% of African Americans, and 20% of whites) and moderate to severe vomiting (reported by 13% of Hispanics and 8% of African Americans, but only 1% of whites).

"This psychological assessment study gives voice to the needs of Hispanic cancer patients who demonstrate greater distress and oncology symptoms [than other groups]," Ms. O’Callaghan said.

The silver lining in the study, she noted, was that Hispanic patients were also more likely than non-Hispanic patients, 26% vs. 21%, to be interested in receiving counseling for their emotional problems.

Coauthor Alyson B. Moadel, Ph.D., director of psychosocial oncology at the Albert Einstein Cancer Center, highlighted "a very big effort ... in terms of quality improvement," in part in response to the study findings.

One specific intervention is a volunteer companion program offering one-to-one support for cancer patients as they receive treatment for cancer, Dr. Moadel said, after Ms. O’Callaghan’s presentation at the meeting.

The study was funded by the Entertainment Industry Foundation; none of the authors reported any relevant financial disclosures.

MIAMI – Hispanic patients reported significantly higher rates of pain, numbness, cognition difficulties, vomiting, and severe sadness than non-Hispanics in a survey of 622 cancer patients awaiting appointments at three hospitals in the Bronx, New York City’s poorest borough.

"Hispanic patients consistently reported more emotional and practical complaints contributing to overall distress," Katie O'Callaghan reported at the annual meeting of the American Psychosocial Oncology Society.

"These are alarming results for us," she said.

Outpatients interviewed for the survey roughly reflected the demographics of the Bronx, a highly diverse, densely populated county where 5,000 new cancer cases are diagnosed each year. They were approached at Montefiore, Jacobi, and Lincoln hospitals.

With a mean age of 58 years (range, 18-100), the group included non-Hispanic whites (15%), African Americans (32%), and Hispanics (45%) with family origins in Mexico, the Caribbean, and South and Central America. Nearly three-quarters, 73%, were women. The most common cancers were breast (29%), gynecologic (14%), hematologic (10%), colorectal (9%), lung (7%), and prostate (3%).

Ms. O’Callaghan, research coordinator at Albert Einstein College of Medicine, New York, noted that among 256 Hispanics who completed the oral survey, 51% were Spanish-language dominant, reporting little or no English fluency. Communication barriers might be one explanation for the marked disparity in reports of physical symptoms, she suggested.

Indeed, on some measures, differences were seen between Hispanic patients who spoke English and those who did not. For example, 64% of Spanish-dominant Hispanics reported fatigue, compared with 49% of English-dominant Hispanic patients, a significant difference (P less than .05).

Spanish-dominant Hispanic patients also reported more practical problems (such as housing, transportation, and child care problems) as contributors to their distress (P less than .05).

But major differences persisted among the ethnic groups surveyed.

Overall, the same percentage – 49.5% – of Hispanic and white patients expressed clinically significant levels of distress – a composite measure that consists of 34 physical, practical, emotional, and spiritual/religious factors – compared with 42.5% of African Americans.

But 45% of Hispanic patients reported moderate to severe pain, more than twice the percentage of whites (20%) and substantially more than African Americans (37%). The differences among the three ethnic groups were significant (P less than .01).

Moderate to severe problems with cognition were reported by similar percentages of African Americans and whites (20% and 19%), but 31% of Hispanics, a difference significant at the P less than .05 level.

Sadness was reported as moderate to severe by 41% of Hispanics, and was significantly more distressful than in non-Hispanics in the survey (P less than .05). Again, about equal percentages of whites and African Americans reported great sadness (31% and 29%).

Divergence by ethnicity also was seen for moderate to severe numbness (reported by 39% of Hispanics, 30% of African Americans, and 20% of whites) and moderate to severe vomiting (reported by 13% of Hispanics and 8% of African Americans, but only 1% of whites).

"This psychological assessment study gives voice to the needs of Hispanic cancer patients who demonstrate greater distress and oncology symptoms [than other groups]," Ms. O’Callaghan said.

The silver lining in the study, she noted, was that Hispanic patients were also more likely than non-Hispanic patients, 26% vs. 21%, to be interested in receiving counseling for their emotional problems.

Coauthor Alyson B. Moadel, Ph.D., director of psychosocial oncology at the Albert Einstein Cancer Center, highlighted "a very big effort ... in terms of quality improvement," in part in response to the study findings.

One specific intervention is a volunteer companion program offering one-to-one support for cancer patients as they receive treatment for cancer, Dr. Moadel said, after Ms. O’Callaghan’s presentation at the meeting.

The study was funded by the Entertainment Industry Foundation; none of the authors reported any relevant financial disclosures.

The first generic formulation of the selective serotonin reuptake inhibitor escitalopram has been approved by the Food and Drug Administration, the agency announced on March 14.

In a statement, the FDA said that generic escitalopram – in 5-mg, 10-mg, and 20-mg doses – manufactured by Teva Pharmaceutical Industries/IVAX Pharmaceuticals, has been approved for treating depression and generalized anxiety disorder in adults. Escitalopram initially was approved in 2002 and is marketed as Lexapro by Forest Laboratories.

Teva has 180 days of generic drug "exclusivity," during which time the FDA cannot approve any other generic formulation of escitalopram, the statement said.

For more information on generic drugs, click here to access the FDA site.

The first generic formulation of the selective serotonin reuptake inhibitor escitalopram has been approved by the Food and Drug Administration, the agency announced on March 14.

In a statement, the FDA said that generic escitalopram – in 5-mg, 10-mg, and 20-mg doses – manufactured by Teva Pharmaceutical Industries/IVAX Pharmaceuticals, has been approved for treating depression and generalized anxiety disorder in adults. Escitalopram initially was approved in 2002 and is marketed as Lexapro by Forest Laboratories.

Teva has 180 days of generic drug "exclusivity," during which time the FDA cannot approve any other generic formulation of escitalopram, the statement said.

For more information on generic drugs, click here to access the FDA site.

The first generic formulation of the selective serotonin reuptake inhibitor escitalopram has been approved by the Food and Drug Administration, the agency announced on March 14.

In a statement, the FDA said that generic escitalopram – in 5-mg, 10-mg, and 20-mg doses – manufactured by Teva Pharmaceutical Industries/IVAX Pharmaceuticals, has been approved for treating depression and generalized anxiety disorder in adults. Escitalopram initially was approved in 2002 and is marketed as Lexapro by Forest Laboratories.

Teva has 180 days of generic drug "exclusivity," during which time the FDA cannot approve any other generic formulation of escitalopram, the statement said.

For more information on generic drugs, click here to access the FDA site.

In patients with rheumatoid arthritis, higher disease activity scores were associated with more severe depression, both when measured at the same time and when measured 6 months apart, suggesting that the impact the two factors have on each other persists over time.

Similarly, depression predicted increased disease activity later.

The findings, while not necessarily causal, "support the notion that in patients with more severe depressed mood, disease activity is probably greater, not only at the same time but also several months later, and that in patients with more swollen and painful joints, psychological distress is probably greater at the same time and later on," wrote Dr. Cécile L. Overman, of Utrecht University (the Netherlands), and associates. The report was published online in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011 Sept. 14 [doi: 10.1136/annrheumdis-2011-200338]).

Dr. Overman, of the department of clinical and health psychology at Utrecht University, looked at 545 patients with a recent diagnosis of rheumatoid arthritis (RA) recruited between 1990 and 2002 in the Utrecht region. The patients were enrolled in a prospective drug trial at the time.

Patients with comorbid psychiatric disorders or drug use were excluded from the study.

Psychological distress was assessed at baseline, before randomization, and then annually for 5 years using the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL) questionnaire. The anxiety portion of IRGL consists of 10 items (scored from 10 to 40) derived from the Spielberger state–trait anxiety inventory; the depressed mood scale consists of six items (scored from 0 to 24).

Disease activity according to erythrocyte sedimentation rate (ESR) and the Thompson articular index was assessed at baseline, every 3 months for the first 2 years, and every 6 months for the next 3 years.

At baseline, the authors found that 45% of patients had a depressed mood according to the IRGL scale, while 36% had anxiety.

Also at baseline, the mean Thompson joint index was 146.0, while the mean ESR was 41.1 mm/hour.

Overall, these high levels of both disease activity and psychological distress decreased sharply in the first year, and continued to decrease over the course of the study, reported the authors, although 26% of patients still experienced depressed mood after 5 years and 23% reported anxiety.

However, looking prospectively, the authors found that scores exceeding zero on the depressed mood scale were associated with a higher Thompson joint score (P = .03) and a higher ESR (P = .04) 6 months later.

Similarly, a higher Thompson joint score was associated with higher levels of depressed mood (P = .03) and anxiety (P = .02) at assessments occurring 6 months afterward.

On the other hand, elevated anxiety scores were not associated with higher disease activity later on.

"Our data do not support the notion that psychological stress may cause disease flares," despite "weak" evidence that stress may exacerbate disease activity, they wrote.

Nor did elevated ESR levels predict psychological distress down the line.

The authors did admit to several weaknesses in their study. For one, "we used existing data with relatively long intervals between assessments," wrote Dr. Overman. "More frequent monitoring, for example, every 3 months during 5 years, will increase the chance of finding disease flares and substantial mood changes."

Additionally, ESR levels and the Thompson joint index are not the only measurements of disease activity available. The authors pointed out that their findings "do not generalize to cytokine and hypothalamic–pituitary–adrenal axis functioning," for example.

The authors disclosed no individual conflicts of interest in regard to this study, which was funded by grants from Utrecht University and the Dutch Arthritis Association.

In patients with rheumatoid arthritis, higher disease activity scores were associated with more severe depression, both when measured at the same time and when measured 6 months apart, suggesting that the impact the two factors have on each other persists over time.

Similarly, depression predicted increased disease activity later.

The findings, while not necessarily causal, "support the notion that in patients with more severe depressed mood, disease activity is probably greater, not only at the same time but also several months later, and that in patients with more swollen and painful joints, psychological distress is probably greater at the same time and later on," wrote Dr. Cécile L. Overman, of Utrecht University (the Netherlands), and associates. The report was published online in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011 Sept. 14 [doi: 10.1136/annrheumdis-2011-200338]).

Dr. Overman, of the department of clinical and health psychology at Utrecht University, looked at 545 patients with a recent diagnosis of rheumatoid arthritis (RA) recruited between 1990 and 2002 in the Utrecht region. The patients were enrolled in a prospective drug trial at the time.

Patients with comorbid psychiatric disorders or drug use were excluded from the study.

Psychological distress was assessed at baseline, before randomization, and then annually for 5 years using the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL) questionnaire. The anxiety portion of IRGL consists of 10 items (scored from 10 to 40) derived from the Spielberger state–trait anxiety inventory; the depressed mood scale consists of six items (scored from 0 to 24).

Disease activity according to erythrocyte sedimentation rate (ESR) and the Thompson articular index was assessed at baseline, every 3 months for the first 2 years, and every 6 months for the next 3 years.

At baseline, the authors found that 45% of patients had a depressed mood according to the IRGL scale, while 36% had anxiety.

Also at baseline, the mean Thompson joint index was 146.0, while the mean ESR was 41.1 mm/hour.

Overall, these high levels of both disease activity and psychological distress decreased sharply in the first year, and continued to decrease over the course of the study, reported the authors, although 26% of patients still experienced depressed mood after 5 years and 23% reported anxiety.

However, looking prospectively, the authors found that scores exceeding zero on the depressed mood scale were associated with a higher Thompson joint score (P = .03) and a higher ESR (P = .04) 6 months later.

Similarly, a higher Thompson joint score was associated with higher levels of depressed mood (P = .03) and anxiety (P = .02) at assessments occurring 6 months afterward.

On the other hand, elevated anxiety scores were not associated with higher disease activity later on.

"Our data do not support the notion that psychological stress may cause disease flares," despite "weak" evidence that stress may exacerbate disease activity, they wrote.

Nor did elevated ESR levels predict psychological distress down the line.

The authors did admit to several weaknesses in their study. For one, "we used existing data with relatively long intervals between assessments," wrote Dr. Overman. "More frequent monitoring, for example, every 3 months during 5 years, will increase the chance of finding disease flares and substantial mood changes."

Additionally, ESR levels and the Thompson joint index are not the only measurements of disease activity available. The authors pointed out that their findings "do not generalize to cytokine and hypothalamic–pituitary–adrenal axis functioning," for example.

The authors disclosed no individual conflicts of interest in regard to this study, which was funded by grants from Utrecht University and the Dutch Arthritis Association.

In patients with rheumatoid arthritis, higher disease activity scores were associated with more severe depression, both when measured at the same time and when measured 6 months apart, suggesting that the impact the two factors have on each other persists over time.

Similarly, depression predicted increased disease activity later.

The findings, while not necessarily causal, "support the notion that in patients with more severe depressed mood, disease activity is probably greater, not only at the same time but also several months later, and that in patients with more swollen and painful joints, psychological distress is probably greater at the same time and later on," wrote Dr. Cécile L. Overman, of Utrecht University (the Netherlands), and associates. The report was published online in Annals of the Rheumatic Diseases (Ann. Rheum. Dis. 2011 Sept. 14 [doi: 10.1136/annrheumdis-2011-200338]).

Dr. Overman, of the department of clinical and health psychology at Utrecht University, looked at 545 patients with a recent diagnosis of rheumatoid arthritis (RA) recruited between 1990 and 2002 in the Utrecht region. The patients were enrolled in a prospective drug trial at the time.

Patients with comorbid psychiatric disorders or drug use were excluded from the study.

Psychological distress was assessed at baseline, before randomization, and then annually for 5 years using the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL) questionnaire. The anxiety portion of IRGL consists of 10 items (scored from 10 to 40) derived from the Spielberger state–trait anxiety inventory; the depressed mood scale consists of six items (scored from 0 to 24).

Disease activity according to erythrocyte sedimentation rate (ESR) and the Thompson articular index was assessed at baseline, every 3 months for the first 2 years, and every 6 months for the next 3 years.

At baseline, the authors found that 45% of patients had a depressed mood according to the IRGL scale, while 36% had anxiety.

Also at baseline, the mean Thompson joint index was 146.0, while the mean ESR was 41.1 mm/hour.

Overall, these high levels of both disease activity and psychological distress decreased sharply in the first year, and continued to decrease over the course of the study, reported the authors, although 26% of patients still experienced depressed mood after 5 years and 23% reported anxiety.

However, looking prospectively, the authors found that scores exceeding zero on the depressed mood scale were associated with a higher Thompson joint score (P = .03) and a higher ESR (P = .04) 6 months later.

Similarly, a higher Thompson joint score was associated with higher levels of depressed mood (P = .03) and anxiety (P = .02) at assessments occurring 6 months afterward.

On the other hand, elevated anxiety scores were not associated with higher disease activity later on.

"Our data do not support the notion that psychological stress may cause disease flares," despite "weak" evidence that stress may exacerbate disease activity, they wrote.

Nor did elevated ESR levels predict psychological distress down the line.

The authors did admit to several weaknesses in their study. For one, "we used existing data with relatively long intervals between assessments," wrote Dr. Overman. "More frequent monitoring, for example, every 3 months during 5 years, will increase the chance of finding disease flares and substantial mood changes."

Additionally, ESR levels and the Thompson joint index are not the only measurements of disease activity available. The authors pointed out that their findings "do not generalize to cytokine and hypothalamic–pituitary–adrenal axis functioning," for example.

The authors disclosed no individual conflicts of interest in regard to this study, which was funded by grants from Utrecht University and the Dutch Arthritis Association.

WASHINGTON – Higher levels of stress may partially account for aggressive tumor growth in African American and Hispanic women with breast cancer, according to Garth H. Rauscher, Ph.D., of the University of Illinois at Chicago.

This is one of the first studies to look closely at the potential role of psychosocial stress on tumor progression in breast cancer, said Dr. Rauscher, an associate professor of epidemiology at the university’s School of Public Health. However, he acknowledged that the study is "flawed" because it is cross-sectional and has other limitations. "This is definitely an exploratory study," Dr. Rauscher said at the American Association for Cancer Research Science of Cancer Health Disparities meeting.

It was already known, especially in Chicago, that there was a wide disparity in mortality rates between black women and white women, said Dr. Rauscher. The data are not as well defined for Hispanic women, he said. Tumor aggressiveness likely contributes to higher mortality rates in the minorities. Both African Americans and Hispanics generally have higher-grade tumors and hormone receptor–negative tumors, said Dr. Rauscher. The researchers wanted to investigate why these women have the more aggressive tumor types.

They chose to examine psychosocial factors.

Dr. Rauscher and his colleagues examined associations between patient-reported stress and aggressive breast cancer in a cross-sectional study of 397 non-Hispanic whites, 411 non-Hispanic blacks, and 181 Hispanics. Data were collected through patient interviews and medical record extraction. Stress was assessed using the four-item Cohen Perceived Stress Subscale, the UCLA Loneliness Scale, and the Cockburn psychological consequences scale. The three scales were combined into a single, standardized stress score.

Patients were interviewed just after their diagnosis of breast cancer. Dr. Rauscher explained that the researchers assumed that if patients were experiencing high stress post diagnosis, they were likely to have been under stress before diagnosis as well. But he acknowledged that this assumption is a major limitation of the study.

Of 989 patients, the researchers were able to get tumor grades for 772: 149 had low-grade tumors; 308 were intermediate, and 315 were high-grade tumors. A total of 21% (66 of 315) of patients with high-grade tumors reported elevated stress, 19% (58 of 308) of patients with intermediate-grade tumors reported elevated stress, and 11% (16 of 149) of patients with low-grade tumors reported elevated stress.

The differences were statistically significant, until Dr. Rauscher and his colleagues adjusted for age, treatment, income, and other factors.

A total of 28% of women with hormone receptor–negative tumors reported stress, compared with 14% of those with receptor-positive growths. Patients with hormone receptor–negative disease reported one-third of a standard deviation higher than did patients with receptor-positive disease (P = .0003). The difference held up after adjustment, Dr. Rauscher said.

Overall, psychosocial stress scores were higher for black and Hispanic women than for whites.

There’s still no way to know, however, what accounts for those differences, said Dr. Rauscher. "If you have a more aggressive diagnosis, does that make you worry more? You could certainly put that out there as a possibility," he said. Patients with more aggressive disease might also undergo more aggressive treatment, which could also lead to greater stress, he said. "There could be causal arrows going in both directions here, but we can’t tease that out." Even so, he said, "our results are consistent with a role for stress in the etiology of aggressive breast cancer."

Dr. Rauscher suggested that other researchers could help confirm his work by delving further into existing cohort studies that measured stress and had banked tumor samples. By comparing tumor type to patients reporting stress, they might be able to tease out an association, he said.

Dr. Rauscher reported no conflicts.

WASHINGTON – Higher levels of stress may partially account for aggressive tumor growth in African American and Hispanic women with breast cancer, according to Garth H. Rauscher, Ph.D., of the University of Illinois at Chicago.

This is one of the first studies to look closely at the potential role of psychosocial stress on tumor progression in breast cancer, said Dr. Rauscher, an associate professor of epidemiology at the university’s School of Public Health. However, he acknowledged that the study is "flawed" because it is cross-sectional and has other limitations. "This is definitely an exploratory study," Dr. Rauscher said at the American Association for Cancer Research Science of Cancer Health Disparities meeting.

It was already known, especially in Chicago, that there was a wide disparity in mortality rates between black women and white women, said Dr. Rauscher. The data are not as well defined for Hispanic women, he said. Tumor aggressiveness likely contributes to higher mortality rates in the minorities. Both African Americans and Hispanics generally have higher-grade tumors and hormone receptor–negative tumors, said Dr. Rauscher. The researchers wanted to investigate why these women have the more aggressive tumor types.

They chose to examine psychosocial factors.

Dr. Rauscher and his colleagues examined associations between patient-reported stress and aggressive breast cancer in a cross-sectional study of 397 non-Hispanic whites, 411 non-Hispanic blacks, and 181 Hispanics. Data were collected through patient interviews and medical record extraction. Stress was assessed using the four-item Cohen Perceived Stress Subscale, the UCLA Loneliness Scale, and the Cockburn psychological consequences scale. The three scales were combined into a single, standardized stress score.

Patients were interviewed just after their diagnosis of breast cancer. Dr. Rauscher explained that the researchers assumed that if patients were experiencing high stress post diagnosis, they were likely to have been under stress before diagnosis as well. But he acknowledged that this assumption is a major limitation of the study.

Of 989 patients, the researchers were able to get tumor grades for 772: 149 had low-grade tumors; 308 were intermediate, and 315 were high-grade tumors. A total of 21% (66 of 315) of patients with high-grade tumors reported elevated stress, 19% (58 of 308) of patients with intermediate-grade tumors reported elevated stress, and 11% (16 of 149) of patients with low-grade tumors reported elevated stress.

The differences were statistically significant, until Dr. Rauscher and his colleagues adjusted for age, treatment, income, and other factors.

A total of 28% of women with hormone receptor–negative tumors reported stress, compared with 14% of those with receptor-positive growths. Patients with hormone receptor–negative disease reported one-third of a standard deviation higher than did patients with receptor-positive disease (P = .0003). The difference held up after adjustment, Dr. Rauscher said.

Overall, psychosocial stress scores were higher for black and Hispanic women than for whites.

There’s still no way to know, however, what accounts for those differences, said Dr. Rauscher. "If you have a more aggressive diagnosis, does that make you worry more? You could certainly put that out there as a possibility," he said. Patients with more aggressive disease might also undergo more aggressive treatment, which could also lead to greater stress, he said. "There could be causal arrows going in both directions here, but we can’t tease that out." Even so, he said, "our results are consistent with a role for stress in the etiology of aggressive breast cancer."

Dr. Rauscher suggested that other researchers could help confirm his work by delving further into existing cohort studies that measured stress and had banked tumor samples. By comparing tumor type to patients reporting stress, they might be able to tease out an association, he said.

Dr. Rauscher reported no conflicts.

WASHINGTON – Higher levels of stress may partially account for aggressive tumor growth in African American and Hispanic women with breast cancer, according to Garth H. Rauscher, Ph.D., of the University of Illinois at Chicago.

This is one of the first studies to look closely at the potential role of psychosocial stress on tumor progression in breast cancer, said Dr. Rauscher, an associate professor of epidemiology at the university’s School of Public Health. However, he acknowledged that the study is "flawed" because it is cross-sectional and has other limitations. "This is definitely an exploratory study," Dr. Rauscher said at the American Association for Cancer Research Science of Cancer Health Disparities meeting.

It was already known, especially in Chicago, that there was a wide disparity in mortality rates between black women and white women, said Dr. Rauscher. The data are not as well defined for Hispanic women, he said. Tumor aggressiveness likely contributes to higher mortality rates in the minorities. Both African Americans and Hispanics generally have higher-grade tumors and hormone receptor–negative tumors, said Dr. Rauscher. The researchers wanted to investigate why these women have the more aggressive tumor types.

They chose to examine psychosocial factors.

Dr. Rauscher and his colleagues examined associations between patient-reported stress and aggressive breast cancer in a cross-sectional study of 397 non-Hispanic whites, 411 non-Hispanic blacks, and 181 Hispanics. Data were collected through patient interviews and medical record extraction. Stress was assessed using the four-item Cohen Perceived Stress Subscale, the UCLA Loneliness Scale, and the Cockburn psychological consequences scale. The three scales were combined into a single, standardized stress score.

Patients were interviewed just after their diagnosis of breast cancer. Dr. Rauscher explained that the researchers assumed that if patients were experiencing high stress post diagnosis, they were likely to have been under stress before diagnosis as well. But he acknowledged that this assumption is a major limitation of the study.

Of 989 patients, the researchers were able to get tumor grades for 772: 149 had low-grade tumors; 308 were intermediate, and 315 were high-grade tumors. A total of 21% (66 of 315) of patients with high-grade tumors reported elevated stress, 19% (58 of 308) of patients with intermediate-grade tumors reported elevated stress, and 11% (16 of 149) of patients with low-grade tumors reported elevated stress.

The differences were statistically significant, until Dr. Rauscher and his colleagues adjusted for age, treatment, income, and other factors.

A total of 28% of women with hormone receptor–negative tumors reported stress, compared with 14% of those with receptor-positive growths. Patients with hormone receptor–negative disease reported one-third of a standard deviation higher than did patients with receptor-positive disease (P = .0003). The difference held up after adjustment, Dr. Rauscher said.

Overall, psychosocial stress scores were higher for black and Hispanic women than for whites.

There’s still no way to know, however, what accounts for those differences, said Dr. Rauscher. "If you have a more aggressive diagnosis, does that make you worry more? You could certainly put that out there as a possibility," he said. Patients with more aggressive disease might also undergo more aggressive treatment, which could also lead to greater stress, he said. "There could be causal arrows going in both directions here, but we can’t tease that out." Even so, he said, "our results are consistent with a role for stress in the etiology of aggressive breast cancer."

Dr. Rauscher suggested that other researchers could help confirm his work by delving further into existing cohort studies that measured stress and had banked tumor samples. By comparing tumor type to patients reporting stress, they might be able to tease out an association, he said.

Dr. Rauscher reported no conflicts.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – The use of Internet-based cognitive-behavioral therapy could cure half of patients with internalizing mental disorders, including depression, social phobia, panic disorder, and generalized anxiety disorder, a review of data suggests.

Internalizing disorders account for half of mental disorders, Dr. Gavin P. Andrews said at the annual meeting of the American Psychiatric Association.

"A quarter of the burden of mental disorders is potentially removable by Internet-based cognitive-behavioral therapy" (CBT), said Dr. Andrews, professor of psychiatry at the University of New South Wales, Sydney, Australia. "If our profession could get a handle on effective treatment for internalizing disorders, we’d make a fundamental move forward."

Internet-based CBT is a self-help program mediated through the Internet. The patient is in contact through e-mail with the person directing the therapy, which consists of psychoeducation and various exercises are completed online.

Dr. Andrews and his associates conducted a review of the literature and metaanalysis of data from 22 studies of Internet-based CBT involving 1,746 patients. The effect-size superiority over comparison groups was larger than the effect-size superiority traditionally seen for treatment of anxiety disorders using face-to-face CBT or selective serotonin reuptake inhibitors (SSRIs), compared with control groups, he said.

For each of the disorders (depression, social phobia, panic disorder, and generalized anxiety disorder), the number needed to treat with Internet-based CBT in order to show an effect was two (PLoS One 2010;5:e13196).

"Treat two people and one gets better. This is powerful treatment in psychiatry. It’s powerful treatment in medicine," said Dr. Andrews, who is a member of the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group for the DSM-5.

The effects of Internet-based CBT appear to last, he added. Although the median follow-up time in the studies was approximately 6 months, some Swedish studies had 18-month follow-up data.

"There was no hint of relapse reported in any study, which is just foreign to my experience," he said. "Depression is supposed to be a relapsing and recurring disorder. What on earth is it doing just disappearing after someone does CBT over the Web? This is not what any of us were trained for."

Diagnosis or the type of Internet-based CBT did not predict results. "It’s as though these four disorders have shared commonalities, because they’re responding identically," he said.

Dr. Andrews said the study was commissioned by the Journal of the American Medical Association, which declined to publish the results. He and his associates have now published 15 randomized, controlled trials, including approximately 1,500 people showing the effectiveness of Internet-based CBT, he said.

In a recent randomized, controlled study, Dr. Andrews and his associates tested the third iteration of transdiagnostic Internet-based CBT that they developed for patients with depression, social phobia, panic disorder, or generalized anxiety disorder. The study, recently published online in advance of print, compared 75 patients who underwent the clinician-guided Internet-based CBT or were on a waiting list for treatment. (Behav. Res. and Therapy 2011 [doi: 10.1016/j.brat.2011.03.007]). The effect-size superiority of the Internet-based CBT was 0.6 a measured on the Depression Anxiety Stress Scales, he said, roughly equivalent to effect sizes seen previously with face-to-face CBT or SSRI treatment. Measures of adherence showed that 76% of patients finished all eight of the Internet-based CBT lessons. Therapist guidance amounted to 70 minutes per patient by e-mail or phone over a 10-week period, on average. About 90% of patients said they would recommend the treatment to a friend.

In general, adherence to Internet-based CBT in Dr. Andrews’s studies averages around 75% of patients, "which is definitely better than what we see in our face-to-face clinics," he said. Data from approximately 1,300 Australian primary care physicians who are using Internet-based CBT with their patients suggest that the adherence rate is 54%. "Even 54% is extraordinarily good," Dr. Andrews said.

A separate analysis by Dr. Andrews and his associates suggests that the patients using Internet-based CBT are similar to patients seen in face-to-face CBT clinics. Among patients with depression, most are treatment experienced, with a history of multiple episodes of depression that began before age 20 years. "Those would not be easy cases," he said.

The simplicity, accessibility, and effectiveness of Internet-based CBT make it a powerful tool for treating internalizing mental disorders, but one that could downgrade the central role of the clinician in treating patients with these problems, he suggested. "You and I were trained that we were the key variable, and it offends me" to be usurped, he said facetiously.

What does Internet-based CBT look like?

"It looks like CBT 101. It is dead boring" for clinicians, Dr. Andrews said.

In one version, comic book–like pages with cartoon characters teach the three basic steps to changing one's thinking: Stop and recognize when you have distressing thoughts. Challenge the thought by looking at the evidence against the thought. Change your unrealistic thoughts so that they are more realistic and destructive.

One female character in the cartoon tale gives examples of how she recognized, challenged, and changed her negative thoughts. A male character who has panic disorder and social phobia describes how he does this, too. Another female character with generalized anxiety disorder gives her own examples.

One of the heroines sums it up, "We realized that if we didn't fight against the negative thinking, we’d stay anxious and depressed. We had a choice. We could put up with the negative thoughts, or fight against them. Challenging thoughts really helps."

Dr. Andrews said he has no relevant conflicts of interest.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

HONOLULU – When it comes to working with patients at risk for suicide in psychotherapy, universal themes apply, according to Barbara Stanley, Ph.D.

Be sure to ask patients explicitly about suicide ideation and collaborate with them on a safety plan and other survival strategies. It also is important to consult with other clinicians, said Dr. Stanley, a clinical psychologist who serves as director of the suicide intervention center at New York State Psychiatric Institute.

At her institute, staff members document this information from patients every time. "If there is any suicidal ideation, they have to document a collaborative plan for managing the suicidality," Dr. Stanley said at the annual meeting of the American Psychiatric Association.

"That is important, no matter what kind of therapy you do."

Patients at greatest risk, in order, are those with bipolar disorder, borderline personality disorder, major depression, schizophrenia, and posttraumatic stress disorder.

Cognitive-behavioral therapy and dialectical behavior therapy have the most support in the literature. However, other therapeutic basics should be used when working with suicidal patients.

Monitor patients for suicidal ideation on an ongoing basis and do not make any assumptions, said Dr. Stanley, also a lecturer in psychiatry at Columbia University, New York. Even if your patient appears well, do not assume that she is not suicidal, particularly if an attempt was made previously. Actively inquire about suicidal ideation and suicidal behavior, because patients might not volunteer the information for various reasons. Some patients say they believe their physician "doesn’t want to hear about it"; others fear they will end up admitted to a facility.

A key goal is to work toward "a collaborative relationship that encourages disclosure."

Keeping an approach that is flexible is important, Dr. Stanley said. "A fixed-treatment model is not such a good idea for people who are suicidal." For example, make some provision for increased contact during periods of suicidal crisis and decreased frequency later – as appropriate. Consider between-session communication either by telephone or e-mail. "This can include the patient checking in without the therapist contacting the patient," she said. "I have someone doing that while I’m here at this meeting."

Group therapy sessions, day programs, and other services can provide therapeutic support between consultations. Also use diary cards (or some variant) to track feedback from the patient.

Communicate with other clinicians, especially experienced, trusted colleagues. "When in doubt, consult. Seek support if you feel you are not on the right track or you are not sure."

Balance your concern without being overly anxious; if you cannot tolerate a frank discussion about suicidality, the patients can become more frightened, Dr. Stanley said. "We use a matter-of-fact tone – with no bold letters or parentheses around this – when we talk to patients about suicidality. It’s like asking about anxiety."

In addition, you have to have some sense when you ask about suicidality that a patient is telling the truth. "I tell patients directly that I need to be able to sleep at night. The deal when you are working with me is, ‘We are going to talk about it.’ My deal in return is I will not automatically throw them in the hospital."

Devise a collaborative strategy with your patient to discuss suicidality in advance. Instead of stating, "When you are suicidal, this is what you do," it is better to say, "Let’s figure out together what will work if you become suicidal again," she said. "Many adolescents will tell me that was a ‘one-time thing.’ I say, ‘Humor me, just in case.’"

No patient should leave a first appointment without a safety plan, Dr. Stanley said. This plan is different from a no-suicide contract, which is popular but not very useful, she said, and is built from a perspective that patients are not simply at the mercy of their suicidal feelings. Also, it acknowledges that suicidal feelings tend to ebb and flow. At her facility, patients are taught how to recognize warning signs and how to employ internal coping strategies, for example.

"When someone has suicidal urges, we [typically] tell them to call 911 or a hotline," Dr. Stanley said. "Do we tell patients with anxiety to call a hotline? No, we teach them how to cope."

A greater structuring of treatment can help suicidal patients as well. Prioritize the therapeutic goals and establish ways to review suicidality with the patient. This will help you to stay on a path of change, she said, versus focusing on crisis after crisis. Set an agenda, conduct a behavioral analysis, and balance validation with problem solving, she added.

"Working with suicidal patients is inevitable," Dr. Stanley said. "Many clinicians are likely to experience a suicide of at least one of their patients." A suicide can take a considerable toll on all survivors, including the therapist. More than one-third of therapists reported extreme distress after a patient suicide in a survey (Suicide Life Threat. Behavior 2010;40:328-36).

Shock, guilt, shame, grief, and fear of blame are among the typical reactions that clinicians feel in the wake of a patient suicide, Dr. Stanley said. "We want to try to avoid this for our own sake as well as for the sake of our patient."

"When young therapists ask me, ‘How can I work with this population?’ I say, ‘I try my best to attend to their suicidality in each and every moment I’m with them,’ " Dr. Stanley said. "And then if something happens, I did my best."

About 90 people per day, or more than 33,000 people each year, die by suicide in the United States. "This is the third-leading cause of death in young people," Dr. Stanley said. "More people die by suicide in the U.S. than by homicide."

These figures are probably an underestimate, Dr. Stanley said. Determination of cause of death, suicide versus accident, can be difficult. Coroners sometimes leave cause of death as "questionable" to protect surviving family members.

In addition, an estimated 3-10 suicide attempts take place for every completed suicide. Many attempts never come to the attention of mental health professionals or physicians, although attempts are a strong predictor of another attempt and of committing suicide.

Researchers found 62% of adults received medical attention after an attempt, "which means almost 40% did not," Dr. Stanley said. The 2009 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, also showed that young adults, aged 18 to 25 years, are at highest risk for suicidal ideation, making a plan, and attempting suicide, compared with older adults.

Dr. Stanley said she had no relevant disclosures.

In patients thought to have delusional infestation, neither skin biopsy nor microscopic examination of patient-provided "specimens" is likely to change the clinical diagnosis, according to a report published online May 16 in the Archives of Dermatology.

Performing such analyses might yield other benefits, such as assuring the patient that he or she is being taken seriously, but clinicians should understand that these procedures do not yield any important objective evidence, wrote Sara A. Hylwa, a visiting medical professional for research, and her associates at the Mayo Clinic in Rochester, Minn.

Photo (c) 2009 Elsevier Inc.

Delusional infestation is characterized by patients’ fixed and false belief that their skin is infested by pathogens. These can be animate, such as "bugs," worms, fungi, or bacteria, or they can be inanimate, such as "fibers," wood chips, or small tubes. Patients with this disorder frequently bring in specimens they have collected as proof of the infestation.

Ms. Hylwa and her colleagues performed what they said was "the first study that has addressed the histologic analysis of skin biopsy specimens and patient-provided specimens from a relatively large number of patients presenting with delusional infestation." They examined the records of all 108 patients treated at the Mayo Clinic for the disorder from 2001 to 2007.

Eighty of these patients underwent skin biopsy, 80 brought in specimens, and 52 had both.

Three-fourths of the patients were women, and mean symptom duration was 2 years (range, 2 weeks to 23 years). The patients reported that they were infested with bugs (79%), worms (20%), eggs of unspecified species (3%), fibers (22%), "specks" (7%), "triangles" (2%), granulous material (2%), and/or one each of the following: thorns, splinters, rotting wood fungus, Styrofoam, glass, car oil, nails, and gel.

None of the 121 biopsies (117 skin, 2 tongue, 1 hair, and 1 muscle) demonstrated evidence of infestation, nor did any patient-provided specimen. And among the dozens of other tests performed, such as stool ova and parasite analysis and skin cultures, none showed any evidence of infestation.

Of the 80 patient-provided specimens, all but two contained only insects that do not infest humans and cutaneous debris such as skin flakes, scabs, crusts, and hair. One stool sample contained an earthworm.

Only one patient-provided specimen proved to contain a true parasite (a pubic louse); however, that patient did not have lice, and pubic lice could not account for the patient’s symptoms, which chiefly involved the fingernails. Another patient provided a tick, but a tick could not have produced the skin eruption seen in that patient, the investigators said (Arch. Dermatol. 2011 May 16 [doi:10.1001/archdermatol.2011.114]).

Interestingly, 61% of patients showed some form of dermatitis on skin biopsy, and almost half had excoriations, ulcerations, or erosions. This high prevalence of dermatitis "raises the possibility that atypical sensations in the skin may be precipitated by a true pathologic condition (dermatitis) and interpreted mistakenly by the patient as insects crawling from the skin," the researchers said.

Similarly, cutaneous crusting and debris from scratches and excoriations might be misinterpreted as pathogens that emerged from the skin.

On the other hand, the dermatitis may have been a result, rather than a cause, of the patient’s belief in infestation. Rubbing and picking at the supposedly infested skin could have resulted in contact dermatitis, and many patients reported that they had applied caustic substances to their skin to "get rid of" the infestation, which could have lead to an irritant or allergic contact dermatitis, Ms. Hylwa and her associates wrote.

The findings raise questions about the value of performing skin biopsies and other procedures in these patients.

"Some have proposed that an alliance with a patient is a justification for a skin biopsy, but is it? What is the outcome following a biopsy? Did it improve the outcome of the interaction with the patient? Were patients more likely to be compliant with therapy following a biopsy?" the researchers asked.

No relevant conflicts of interest were reported.

In patients thought to have delusional infestation, neither skin biopsy nor microscopic examination of patient-provided "specimens" is likely to change the clinical diagnosis, according to a report published online May 16 in the Archives of Dermatology.

Performing such analyses might yield other benefits, such as assuring the patient that he or she is being taken seriously, but clinicians should understand that these procedures do not yield any important objective evidence, wrote Sara A. Hylwa, a visiting medical professional for research, and her associates at the Mayo Clinic in Rochester, Minn.

Photo (c) 2009 Elsevier Inc.

Delusional infestation is characterized by patients’ fixed and false belief that their skin is infested by pathogens. These can be animate, such as "bugs," worms, fungi, or bacteria, or they can be inanimate, such as "fibers," wood chips, or small tubes. Patients with this disorder frequently bring in specimens they have collected as proof of the infestation.

Ms. Hylwa and her colleagues performed what they said was "the first study that has addressed the histologic analysis of skin biopsy specimens and patient-provided specimens from a relatively large number of patients presenting with delusional infestation." They examined the records of all 108 patients treated at the Mayo Clinic for the disorder from 2001 to 2007.

Eighty of these patients underwent skin biopsy, 80 brought in specimens, and 52 had both.

Three-fourths of the patients were women, and mean symptom duration was 2 years (range, 2 weeks to 23 years). The patients reported that they were infested with bugs (79%), worms (20%), eggs of unspecified species (3%), fibers (22%), "specks" (7%), "triangles" (2%), granulous material (2%), and/or one each of the following: thorns, splinters, rotting wood fungus, Styrofoam, glass, car oil, nails, and gel.

None of the 121 biopsies (117 skin, 2 tongue, 1 hair, and 1 muscle) demonstrated evidence of infestation, nor did any patient-provided specimen. And among the dozens of other tests performed, such as stool ova and parasite analysis and skin cultures, none showed any evidence of infestation.

Of the 80 patient-provided specimens, all but two contained only insects that do not infest humans and cutaneous debris such as skin flakes, scabs, crusts, and hair. One stool sample contained an earthworm.

Only one patient-provided specimen proved to contain a true parasite (a pubic louse); however, that patient did not have lice, and pubic lice could not account for the patient’s symptoms, which chiefly involved the fingernails. Another patient provided a tick, but a tick could not have produced the skin eruption seen in that patient, the investigators said (Arch. Dermatol. 2011 May 16 [doi:10.1001/archdermatol.2011.114]).

Interestingly, 61% of patients showed some form of dermatitis on skin biopsy, and almost half had excoriations, ulcerations, or erosions. This high prevalence of dermatitis "raises the possibility that atypical sensations in the skin may be precipitated by a true pathologic condition (dermatitis) and interpreted mistakenly by the patient as insects crawling from the skin," the researchers said.

Similarly, cutaneous crusting and debris from scratches and excoriations might be misinterpreted as pathogens that emerged from the skin.

On the other hand, the dermatitis may have been a result, rather than a cause, of the patient’s belief in infestation. Rubbing and picking at the supposedly infested skin could have resulted in contact dermatitis, and many patients reported that they had applied caustic substances to their skin to "get rid of" the infestation, which could have lead to an irritant or allergic contact dermatitis, Ms. Hylwa and her associates wrote.

The findings raise questions about the value of performing skin biopsies and other procedures in these patients.

"Some have proposed that an alliance with a patient is a justification for a skin biopsy, but is it? What is the outcome following a biopsy? Did it improve the outcome of the interaction with the patient? Were patients more likely to be compliant with therapy following a biopsy?" the researchers asked.

No relevant conflicts of interest were reported.

In patients thought to have delusional infestation, neither skin biopsy nor microscopic examination of patient-provided "specimens" is likely to change the clinical diagnosis, according to a report published online May 16 in the Archives of Dermatology.

Performing such analyses might yield other benefits, such as assuring the patient that he or she is being taken seriously, but clinicians should understand that these procedures do not yield any important objective evidence, wrote Sara A. Hylwa, a visiting medical professional for research, and her associates at the Mayo Clinic in Rochester, Minn.

Photo (c) 2009 Elsevier Inc.

Delusional infestation is characterized by patients’ fixed and false belief that their skin is infested by pathogens. These can be animate, such as "bugs," worms, fungi, or bacteria, or they can be inanimate, such as "fibers," wood chips, or small tubes. Patients with this disorder frequently bring in specimens they have collected as proof of the infestation.

Ms. Hylwa and her colleagues performed what they said was "the first study that has addressed the histologic analysis of skin biopsy specimens and patient-provided specimens from a relatively large number of patients presenting with delusional infestation." They examined the records of all 108 patients treated at the Mayo Clinic for the disorder from 2001 to 2007.

Eighty of these patients underwent skin biopsy, 80 brought in specimens, and 52 had both.

Three-fourths of the patients were women, and mean symptom duration was 2 years (range, 2 weeks to 23 years). The patients reported that they were infested with bugs (79%), worms (20%), eggs of unspecified species (3%), fibers (22%), "specks" (7%), "triangles" (2%), granulous material (2%), and/or one each of the following: thorns, splinters, rotting wood fungus, Styrofoam, glass, car oil, nails, and gel.

None of the 121 biopsies (117 skin, 2 tongue, 1 hair, and 1 muscle) demonstrated evidence of infestation, nor did any patient-provided specimen. And among the dozens of other tests performed, such as stool ova and parasite analysis and skin cultures, none showed any evidence of infestation.

Of the 80 patient-provided specimens, all but two contained only insects that do not infest humans and cutaneous debris such as skin flakes, scabs, crusts, and hair. One stool sample contained an earthworm.

Only one patient-provided specimen proved to contain a true parasite (a pubic louse); however, that patient did not have lice, and pubic lice could not account for the patient’s symptoms, which chiefly involved the fingernails. Another patient provided a tick, but a tick could not have produced the skin eruption seen in that patient, the investigators said (Arch. Dermatol. 2011 May 16 [doi:10.1001/archdermatol.2011.114]).

Interestingly, 61% of patients showed some form of dermatitis on skin biopsy, and almost half had excoriations, ulcerations, or erosions. This high prevalence of dermatitis "raises the possibility that atypical sensations in the skin may be precipitated by a true pathologic condition (dermatitis) and interpreted mistakenly by the patient as insects crawling from the skin," the researchers said.

Similarly, cutaneous crusting and debris from scratches and excoriations might be misinterpreted as pathogens that emerged from the skin.

On the other hand, the dermatitis may have been a result, rather than a cause, of the patient’s belief in infestation. Rubbing and picking at the supposedly infested skin could have resulted in contact dermatitis, and many patients reported that they had applied caustic substances to their skin to "get rid of" the infestation, which could have lead to an irritant or allergic contact dermatitis, Ms. Hylwa and her associates wrote.

The findings raise questions about the value of performing skin biopsies and other procedures in these patients.

"Some have proposed that an alliance with a patient is a justification for a skin biopsy, but is it? What is the outcome following a biopsy? Did it improve the outcome of the interaction with the patient? Were patients more likely to be compliant with therapy following a biopsy?" the researchers asked.

No relevant conflicts of interest were reported.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.

DENVER – A simple illusion created using a mirror provides a low-cost, low-risk therapy for phantom limb pain in the intensive care unit, a study has shown.

Investigators at Walter Reed Army Medical Center have reported that mirror therapy for phantom limb pain was strikingly effective in a randomized, sham-controlled trial when used on an outpatient basis in rehabilitation therapy for individuals capable of sitting upright in a chair (N. Engl. J. Med. 2007;357:2206-7). But it can work in a bed-bound ICU patient as well, Dr. Nicholas H. Carter reported at the annual meeting of the American Neuropsychiatric Association.

He presented a case report involving a 24-year-old woman with systemic lupus erythematosus who developed severe, drug-refractory phantom limb and stump pain following a series of surgeries that culminated in an above-the-knee amputation of her left leg. Her hospitalization was prolonged because of numerous complications, including pneumonia, bilateral pneumothoraxes, sepsis, and pericardial effusion with tamponade. She had stump pain that improved only modestly, from 10 on a 10-point scale to 8, in response to hydromorphone. The patient also had two to three episodes of excruciating phantom limb pain per day, each lasting 10-15 minutes; numerous medications failed to provide any relief.

With the patient in a semi–Fowler’s position in her ICU bed and her stump and pelvis draped with sheets, a 2-by-3-foot mirror was positioned between her legs in the parasagittal plane so she could see the reflection of her exposed bare right leg.

Immediately prior to the initial session of mirror therapy the patient rated her stump pain as a 9, and 10 minutes earlier she had experienced what she described as a shock of phantom limb pain. After viewing the mirror for just 3 minutes, the patient reported that her stump pain had decreased to 4, with no further phantom limb sensations, according to Dr. Carter of Brown University, Providence, R.I.

The mirror was brought out again every time the patient felt the onset of phantom limb pain. She reported that 3-5 minutes of viewing the mirror typically decreased the phantom limb pain intensity from 7 to 3. Instead of lasting 10-15 minutes, as previously, the episodes now lasted about 5 minutes and decreased in number from two to three per day to one truncated episode per day or none. This was accompanied by complete resolution of the intense phantom itch.

Interestingly, the patient’s stump pain responded only to her first viewing of the mirror, Dr. Carter said. Subsequent sessions or mirror therapy had no substantial benefit for the stump pain.

This case sheds little new light on the mechanism of benefit for mirror therapy, a topic of considerable debate in the medical literature, he noted.

Some researchers have theorized that limb amputation may cause central neurologic remapping and deranged cortical output, which gets interpreted as pain. The theory that proprioceptive memory of the amputated limb accounts for phantom limb pain enjoys wide popularity.

Regardless, it’s axiomatic that when multiple senses provide conflicting input to the brain, vision trumps. Mirror therapy might activate mirror neurons in the brain hemisphere contralateral to the amputated limb and provide visual feedback against painful proprioceptive stimuli, Dr. Carter suggested.

He said he had no relevant financial disclosures.