Sherry Boschert

SAN FRANCISCO – For much of the past decade, most pregnant women in the United States have not had access to nitrous oxide for analgesia during labor because the only company that sold a nitrous oxide machine for obstetrics in this country stopped making it.

This year, though, "laughing gas" for labor pain is back.

The Nitronox system delivers a fixed mixture of 50% oxygen and 50% nitrous oxide that is safe, effective, inexpensive, simple, and popular with many laboring women, said Judith T. Bishop, C.N.M., M.P.H. Physician supervision is not needed for its use, she added at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco (UCSF).

Sherry Boschert/IMNG Medical Media

Other nitrous oxide systems commonly are used for labor analgesia in the United Kingdom, Canada, Australia, and Scandinavia, and are available in Japan and Israel, but the gas has never caught on extensively in the United States for obstetrics. "I’ve been doing kind of a road show for nitrous oxide for about 7 years now," said Ms. Bishop, professor of obstetrics and gynecology and reproductive sciences at the university. "Ironically, during the entire period that I’ve been enthusiastically sharing my 20 years of experience with nitrous oxide use at UCSF, the nitrous oxide equipment appropriate for use in labor has been unobtainable" in the United States.

Michael Civitello, a salesman for the company that makes the Nitronox system, said the equipment went out of production during changes involving corporate mergers, not for reasons related to the product itself. Parker Hannifin Corporation’s Porter Instrument Division decided to return Nitronox to the market when it realized it still had a sales niche and advocates such as Ms. Bishop built increased interest in its use, he said in an interview at the company’s booth at the meeting. The new system costs approximately $5,000.

Perhaps 20-30 more hospitals and birth centers are expected to be offering nitrous oxide for labor by the end of this year, predicted Ms. Bishop and Mr. Civitello.

Women in labor at UCSF have been offered nitrous oxide for more than 30 years with no break in service because the gas delivery systems were built into the hospital, and are being built into a new UCSF hospital that’s under construction. Ms. Bishop searched and was able to find only three other U.S. hospitals with the ability to offer nitrous oxide during labor: the University of Washington, Seattle ("although they had largely forgotten about it," she said); a hospital in Lewiston, Idaho; and Vanderbilt University in Nashville, Tenn., which got tired of waiting for a nitrous oxide machine to return to the market and bought two used machines on eBay in 2011, Ms. Bishop said.

Data from Vanderbilt from June 2011 to May 2013 show an epidural rate of 40% in its midwifery service, compared with approximately 85% in the rest of the university practice, she said. Twenty percent of women in labor initiated nitrous oxide, and approximately 45% of those converted to epidural analgesia.

Data from 5,987 term singleton pregnancies at UCSF during 2007-2011 show an epidural rate of 76%. Nitrous oxide analgesia was started in 14% of deliveries, 41% of which converted to epidural analgesia.

Those numbers do not include other uses for nitrous oxide on labor and delivery units, she added, including analgesia for women experiencing laceration repair, retained placenta, Foley balloon placement, vaginal exams, and blood draws or IV placement.

For labor, nitrous oxide is an adjunct for pain relief and is not meant to replace other analgesia alternatives, Ms. Bishop said. Its use may allow the woman to delay or avoid using narcotics or epidural anesthesia. Nitrous oxide may be especially useful for women who want an epidural but can’t have one because they arrived at the hospital too late, they have a contraindication such as low platelet levels, or an anesthesiologist is unavailable to administer an epidural.

Another good use of nitrous oxide is for teenage mothers who are "out of control and can’t handle a needle in the back" for epidural analgesia, added Tekoa L. King, C.N.M., M.P.H., also of UCSF.

"There’s an antianxiety effect as well as an analgesic effect," Ms. Bishop said.

Data suggest that about half of women find nitrous oxide to be effective analgesia, better than the satisfaction rate for opioids in labor. That’s "no surprise," because opioids are not very effective in labor, she said. "Bathtubs are rated much more highly than opioids."

Women who report being satisfied with nitrous oxide may not show a decrease in pain scores, she added. With nitrous oxide, they say, "It still hurts, but I don’t care."

Inhaling the gas typically provides some degree of pain relief in less than a minute, and the effect dissipates after another breath or two. Since the first study of its use in labor in 1880, nitrous oxide has proved to be safe, Ms. Bishop said. It does not build up in the mother or fetus, and does not seem to affect contractions, labor progression, or the ability to push. It can be used through the second stage of labor, and there’s no evidence that it affects newborns or breastfeeding.

"You can’t kill somebody with 50/50 nitrous oxide and oxygen," she said.

In the United States, the woman initiates and controls the gas flow through a mask, with the negative pressure from inhalation opening a demand valve that stops gas flow when inhalation ceases. Excess nitrous oxide is scavenged out by suction. It’s meant for intermittent, not continuous, use.

Dosimeter badges worn by obstetrics nurses at UCSF consistently show that staff exposure to nitrous oxide is less than 2 parts per million in an 8-hour period, far below the 25-ppm limit set by the National Institute for Occupational Safety and Health.

It’s important to counsel family members who are trying to be "helpful" that only the woman should hold the mask to her face so that she controls the gas flow. Not all women find it helpful, and some may experience dizziness, drowsiness, or nausea, although those effects usually occur with higher doses of nitrous oxide, not the 50/50 blend with oxygen, Ms. Bishop said.

Usually, the nitrous oxide is more effective if the woman breathes it just before a contraction starts instead of waiting for a contraction, but each woman will find what works for them.

Nitrous oxide use at UCSF increased by 50% after the university expanded the privileges of certified nurse-midwives in 2007 to include initiation of the gas mixture, instead of having to call an anesthesia resident. Now the university is moving toward a standing order allowing registered nurses to initiate nitrous oxide use, similar to a standing order for fentanyl initiation. "I think that’s going to be a huge improvement," Ms. Bishop said.

Ms. Bishop reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – For much of the past decade, most pregnant women in the United States have not had access to nitrous oxide for analgesia during labor because the only company that sold a nitrous oxide machine for obstetrics in this country stopped making it.

This year, though, "laughing gas" for labor pain is back.

The Nitronox system delivers a fixed mixture of 50% oxygen and 50% nitrous oxide that is safe, effective, inexpensive, simple, and popular with many laboring women, said Judith T. Bishop, C.N.M., M.P.H. Physician supervision is not needed for its use, she added at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco (UCSF).

Sherry Boschert/IMNG Medical Media

Other nitrous oxide systems commonly are used for labor analgesia in the United Kingdom, Canada, Australia, and Scandinavia, and are available in Japan and Israel, but the gas has never caught on extensively in the United States for obstetrics. "I’ve been doing kind of a road show for nitrous oxide for about 7 years now," said Ms. Bishop, professor of obstetrics and gynecology and reproductive sciences at the university. "Ironically, during the entire period that I’ve been enthusiastically sharing my 20 years of experience with nitrous oxide use at UCSF, the nitrous oxide equipment appropriate for use in labor has been unobtainable" in the United States.

Michael Civitello, a salesman for the company that makes the Nitronox system, said the equipment went out of production during changes involving corporate mergers, not for reasons related to the product itself. Parker Hannifin Corporation’s Porter Instrument Division decided to return Nitronox to the market when it realized it still had a sales niche and advocates such as Ms. Bishop built increased interest in its use, he said in an interview at the company’s booth at the meeting. The new system costs approximately $5,000.

Perhaps 20-30 more hospitals and birth centers are expected to be offering nitrous oxide for labor by the end of this year, predicted Ms. Bishop and Mr. Civitello.

Women in labor at UCSF have been offered nitrous oxide for more than 30 years with no break in service because the gas delivery systems were built into the hospital, and are being built into a new UCSF hospital that’s under construction. Ms. Bishop searched and was able to find only three other U.S. hospitals with the ability to offer nitrous oxide during labor: the University of Washington, Seattle ("although they had largely forgotten about it," she said); a hospital in Lewiston, Idaho; and Vanderbilt University in Nashville, Tenn., which got tired of waiting for a nitrous oxide machine to return to the market and bought two used machines on eBay in 2011, Ms. Bishop said.

Data from Vanderbilt from June 2011 to May 2013 show an epidural rate of 40% in its midwifery service, compared with approximately 85% in the rest of the university practice, she said. Twenty percent of women in labor initiated nitrous oxide, and approximately 45% of those converted to epidural analgesia.

Data from 5,987 term singleton pregnancies at UCSF during 2007-2011 show an epidural rate of 76%. Nitrous oxide analgesia was started in 14% of deliveries, 41% of which converted to epidural analgesia.

Those numbers do not include other uses for nitrous oxide on labor and delivery units, she added, including analgesia for women experiencing laceration repair, retained placenta, Foley balloon placement, vaginal exams, and blood draws or IV placement.

For labor, nitrous oxide is an adjunct for pain relief and is not meant to replace other analgesia alternatives, Ms. Bishop said. Its use may allow the woman to delay or avoid using narcotics or epidural anesthesia. Nitrous oxide may be especially useful for women who want an epidural but can’t have one because they arrived at the hospital too late, they have a contraindication such as low platelet levels, or an anesthesiologist is unavailable to administer an epidural.

Another good use of nitrous oxide is for teenage mothers who are "out of control and can’t handle a needle in the back" for epidural analgesia, added Tekoa L. King, C.N.M., M.P.H., also of UCSF.

"There’s an antianxiety effect as well as an analgesic effect," Ms. Bishop said.

Data suggest that about half of women find nitrous oxide to be effective analgesia, better than the satisfaction rate for opioids in labor. That’s "no surprise," because opioids are not very effective in labor, she said. "Bathtubs are rated much more highly than opioids."

Women who report being satisfied with nitrous oxide may not show a decrease in pain scores, she added. With nitrous oxide, they say, "It still hurts, but I don’t care."

Inhaling the gas typically provides some degree of pain relief in less than a minute, and the effect dissipates after another breath or two. Since the first study of its use in labor in 1880, nitrous oxide has proved to be safe, Ms. Bishop said. It does not build up in the mother or fetus, and does not seem to affect contractions, labor progression, or the ability to push. It can be used through the second stage of labor, and there’s no evidence that it affects newborns or breastfeeding.

"You can’t kill somebody with 50/50 nitrous oxide and oxygen," she said.

In the United States, the woman initiates and controls the gas flow through a mask, with the negative pressure from inhalation opening a demand valve that stops gas flow when inhalation ceases. Excess nitrous oxide is scavenged out by suction. It’s meant for intermittent, not continuous, use.

Dosimeter badges worn by obstetrics nurses at UCSF consistently show that staff exposure to nitrous oxide is less than 2 parts per million in an 8-hour period, far below the 25-ppm limit set by the National Institute for Occupational Safety and Health.

It’s important to counsel family members who are trying to be "helpful" that only the woman should hold the mask to her face so that she controls the gas flow. Not all women find it helpful, and some may experience dizziness, drowsiness, or nausea, although those effects usually occur with higher doses of nitrous oxide, not the 50/50 blend with oxygen, Ms. Bishop said.

Usually, the nitrous oxide is more effective if the woman breathes it just before a contraction starts instead of waiting for a contraction, but each woman will find what works for them.

Nitrous oxide use at UCSF increased by 50% after the university expanded the privileges of certified nurse-midwives in 2007 to include initiation of the gas mixture, instead of having to call an anesthesia resident. Now the university is moving toward a standing order allowing registered nurses to initiate nitrous oxide use, similar to a standing order for fentanyl initiation. "I think that’s going to be a huge improvement," Ms. Bishop said.

Ms. Bishop reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – For much of the past decade, most pregnant women in the United States have not had access to nitrous oxide for analgesia during labor because the only company that sold a nitrous oxide machine for obstetrics in this country stopped making it.

This year, though, "laughing gas" for labor pain is back.

The Nitronox system delivers a fixed mixture of 50% oxygen and 50% nitrous oxide that is safe, effective, inexpensive, simple, and popular with many laboring women, said Judith T. Bishop, C.N.M., M.P.H. Physician supervision is not needed for its use, she added at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco (UCSF).

Sherry Boschert/IMNG Medical Media

Other nitrous oxide systems commonly are used for labor analgesia in the United Kingdom, Canada, Australia, and Scandinavia, and are available in Japan and Israel, but the gas has never caught on extensively in the United States for obstetrics. "I’ve been doing kind of a road show for nitrous oxide for about 7 years now," said Ms. Bishop, professor of obstetrics and gynecology and reproductive sciences at the university. "Ironically, during the entire period that I’ve been enthusiastically sharing my 20 years of experience with nitrous oxide use at UCSF, the nitrous oxide equipment appropriate for use in labor has been unobtainable" in the United States.

Michael Civitello, a salesman for the company that makes the Nitronox system, said the equipment went out of production during changes involving corporate mergers, not for reasons related to the product itself. Parker Hannifin Corporation’s Porter Instrument Division decided to return Nitronox to the market when it realized it still had a sales niche and advocates such as Ms. Bishop built increased interest in its use, he said in an interview at the company’s booth at the meeting. The new system costs approximately $5,000.

Perhaps 20-30 more hospitals and birth centers are expected to be offering nitrous oxide for labor by the end of this year, predicted Ms. Bishop and Mr. Civitello.

Women in labor at UCSF have been offered nitrous oxide for more than 30 years with no break in service because the gas delivery systems were built into the hospital, and are being built into a new UCSF hospital that’s under construction. Ms. Bishop searched and was able to find only three other U.S. hospitals with the ability to offer nitrous oxide during labor: the University of Washington, Seattle ("although they had largely forgotten about it," she said); a hospital in Lewiston, Idaho; and Vanderbilt University in Nashville, Tenn., which got tired of waiting for a nitrous oxide machine to return to the market and bought two used machines on eBay in 2011, Ms. Bishop said.

Data from Vanderbilt from June 2011 to May 2013 show an epidural rate of 40% in its midwifery service, compared with approximately 85% in the rest of the university practice, she said. Twenty percent of women in labor initiated nitrous oxide, and approximately 45% of those converted to epidural analgesia.

Data from 5,987 term singleton pregnancies at UCSF during 2007-2011 show an epidural rate of 76%. Nitrous oxide analgesia was started in 14% of deliveries, 41% of which converted to epidural analgesia.

Those numbers do not include other uses for nitrous oxide on labor and delivery units, she added, including analgesia for women experiencing laceration repair, retained placenta, Foley balloon placement, vaginal exams, and blood draws or IV placement.

For labor, nitrous oxide is an adjunct for pain relief and is not meant to replace other analgesia alternatives, Ms. Bishop said. Its use may allow the woman to delay or avoid using narcotics or epidural anesthesia. Nitrous oxide may be especially useful for women who want an epidural but can’t have one because they arrived at the hospital too late, they have a contraindication such as low platelet levels, or an anesthesiologist is unavailable to administer an epidural.

Another good use of nitrous oxide is for teenage mothers who are "out of control and can’t handle a needle in the back" for epidural analgesia, added Tekoa L. King, C.N.M., M.P.H., also of UCSF.

"There’s an antianxiety effect as well as an analgesic effect," Ms. Bishop said.

Data suggest that about half of women find nitrous oxide to be effective analgesia, better than the satisfaction rate for opioids in labor. That’s "no surprise," because opioids are not very effective in labor, she said. "Bathtubs are rated much more highly than opioids."

Women who report being satisfied with nitrous oxide may not show a decrease in pain scores, she added. With nitrous oxide, they say, "It still hurts, but I don’t care."

Inhaling the gas typically provides some degree of pain relief in less than a minute, and the effect dissipates after another breath or two. Since the first study of its use in labor in 1880, nitrous oxide has proved to be safe, Ms. Bishop said. It does not build up in the mother or fetus, and does not seem to affect contractions, labor progression, or the ability to push. It can be used through the second stage of labor, and there’s no evidence that it affects newborns or breastfeeding.

"You can’t kill somebody with 50/50 nitrous oxide and oxygen," she said.

In the United States, the woman initiates and controls the gas flow through a mask, with the negative pressure from inhalation opening a demand valve that stops gas flow when inhalation ceases. Excess nitrous oxide is scavenged out by suction. It’s meant for intermittent, not continuous, use.

Dosimeter badges worn by obstetrics nurses at UCSF consistently show that staff exposure to nitrous oxide is less than 2 parts per million in an 8-hour period, far below the 25-ppm limit set by the National Institute for Occupational Safety and Health.

It’s important to counsel family members who are trying to be "helpful" that only the woman should hold the mask to her face so that she controls the gas flow. Not all women find it helpful, and some may experience dizziness, drowsiness, or nausea, although those effects usually occur with higher doses of nitrous oxide, not the 50/50 blend with oxygen, Ms. Bishop said.

Usually, the nitrous oxide is more effective if the woman breathes it just before a contraction starts instead of waiting for a contraction, but each woman will find what works for them.

Nitrous oxide use at UCSF increased by 50% after the university expanded the privileges of certified nurse-midwives in 2007 to include initiation of the gas mixture, instead of having to call an anesthesia resident. Now the university is moving toward a standing order allowing registered nurses to initiate nitrous oxide use, similar to a standing order for fentanyl initiation. "I think that’s going to be a huge improvement," Ms. Bishop said.

Ms. Bishop reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

The public debate about whether television and movies influence personality or behavior usually focuses on violence – does violent content increase the likelihood of violent behavior?

Dr. Audrey Longson began worrying about a different trait – narcissism when she saw her younger sister’s crowd become big fans of reality TV shows. You know, the kind of TV shows whose subjects are vain enough to assume that their lives are so interesting that millions of people should tune in every week and watch them.

Tim Lundin/The Heart Truth

She wondered whether excessive viewing of reality TV shows, which claim to portray "real life," might normalize narcissistic behaviors and contribute to a higher prevalence of narcissistic tendencies.

Or, as Dr. Longson put it, "Is ‘Keeping Up With the Kardashians’ keeping you down?"

In simple terms, narcissism is defined as a personality trait characterized by egocentricity, excessive vanity and pride, and self-serving behavior that’s often detrimental to others. Traditionally, psychiatrists have looked to a patient’s "family of origin" as a potential cause of narcissism, but other environmental influences are getting increased attention.

Dr. Longson, her sister, and a male cousin recruited 159 adult survey subjects through posts shared on Facebook that redirected participants to three Web-based surveys: the Narcissistic Personality Inventory (NPI); the Rosenberg Self-Esteem Scale (RSE), and a questionnaire about demographics and reality TV viewing practices.

Watching reality TV didn’t appear to predict the development of narcissistic traits, but it’s too soon to dismiss the idea of reality TV viewership as an environmental factor related to narcissism, her findings suggest. It’s just unclear whether the narcissism is the chicken or the egg, said Dr. Longson, who is in private practice in Teaneck, N.J.

She found some trends suggesting that the kind of reality TV show might matter. People who watched voyeuristic shows such as the Kardashians or one of the "Real Housewives" iterations were more likely to feel that they had power over others and that they were more special than others. Watching skill-based reality shows such as "Survivor" also was associated with higher "special person" scores, but not as high as with watching the voyeuristic shows. The skill-based viewers also showed modestly increased scores for exhibitionism.

Watching educational reality shows, on the other hand, produced no statistically significant association with narcissistic traits. In fact, there were hints of a mild inverse relationship – watching the educational shows might be associated with less-narcissistic NPI scores, Dr. Longson said at the annual meeting of the American Psychiatric Association in San Francisco.

It’s difficult to determine if watching certain kinds of reality TV is a cause or a symptom of narcissism (or neither), but there’s enough here to warrant more research, she believes.

And it’s enough for Dr. Longson to offer some advice to her sister’s crowd and to society as a whole: "In our increasingly consumer-driven culture, we should take a moment and stop and consider what we’re consuming."

Dr. Longson reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

The public debate about whether television and movies influence personality or behavior usually focuses on violence – does violent content increase the likelihood of violent behavior?

Dr. Audrey Longson began worrying about a different trait – narcissism when she saw her younger sister’s crowd become big fans of reality TV shows. You know, the kind of TV shows whose subjects are vain enough to assume that their lives are so interesting that millions of people should tune in every week and watch them.

Tim Lundin/The Heart Truth

She wondered whether excessive viewing of reality TV shows, which claim to portray "real life," might normalize narcissistic behaviors and contribute to a higher prevalence of narcissistic tendencies.

Or, as Dr. Longson put it, "Is ‘Keeping Up With the Kardashians’ keeping you down?"

In simple terms, narcissism is defined as a personality trait characterized by egocentricity, excessive vanity and pride, and self-serving behavior that’s often detrimental to others. Traditionally, psychiatrists have looked to a patient’s "family of origin" as a potential cause of narcissism, but other environmental influences are getting increased attention.

Dr. Longson, her sister, and a male cousin recruited 159 adult survey subjects through posts shared on Facebook that redirected participants to three Web-based surveys: the Narcissistic Personality Inventory (NPI); the Rosenberg Self-Esteem Scale (RSE), and a questionnaire about demographics and reality TV viewing practices.

Watching reality TV didn’t appear to predict the development of narcissistic traits, but it’s too soon to dismiss the idea of reality TV viewership as an environmental factor related to narcissism, her findings suggest. It’s just unclear whether the narcissism is the chicken or the egg, said Dr. Longson, who is in private practice in Teaneck, N.J.

She found some trends suggesting that the kind of reality TV show might matter. People who watched voyeuristic shows such as the Kardashians or one of the "Real Housewives" iterations were more likely to feel that they had power over others and that they were more special than others. Watching skill-based reality shows such as "Survivor" also was associated with higher "special person" scores, but not as high as with watching the voyeuristic shows. The skill-based viewers also showed modestly increased scores for exhibitionism.

Watching educational reality shows, on the other hand, produced no statistically significant association with narcissistic traits. In fact, there were hints of a mild inverse relationship – watching the educational shows might be associated with less-narcissistic NPI scores, Dr. Longson said at the annual meeting of the American Psychiatric Association in San Francisco.

It’s difficult to determine if watching certain kinds of reality TV is a cause or a symptom of narcissism (or neither), but there’s enough here to warrant more research, she believes.

And it’s enough for Dr. Longson to offer some advice to her sister’s crowd and to society as a whole: "In our increasingly consumer-driven culture, we should take a moment and stop and consider what we’re consuming."

Dr. Longson reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

The public debate about whether television and movies influence personality or behavior usually focuses on violence – does violent content increase the likelihood of violent behavior?

Dr. Audrey Longson began worrying about a different trait – narcissism when she saw her younger sister’s crowd become big fans of reality TV shows. You know, the kind of TV shows whose subjects are vain enough to assume that their lives are so interesting that millions of people should tune in every week and watch them.

Tim Lundin/The Heart Truth

She wondered whether excessive viewing of reality TV shows, which claim to portray "real life," might normalize narcissistic behaviors and contribute to a higher prevalence of narcissistic tendencies.

Or, as Dr. Longson put it, "Is ‘Keeping Up With the Kardashians’ keeping you down?"

In simple terms, narcissism is defined as a personality trait characterized by egocentricity, excessive vanity and pride, and self-serving behavior that’s often detrimental to others. Traditionally, psychiatrists have looked to a patient’s "family of origin" as a potential cause of narcissism, but other environmental influences are getting increased attention.

Dr. Longson, her sister, and a male cousin recruited 159 adult survey subjects through posts shared on Facebook that redirected participants to three Web-based surveys: the Narcissistic Personality Inventory (NPI); the Rosenberg Self-Esteem Scale (RSE), and a questionnaire about demographics and reality TV viewing practices.

Watching reality TV didn’t appear to predict the development of narcissistic traits, but it’s too soon to dismiss the idea of reality TV viewership as an environmental factor related to narcissism, her findings suggest. It’s just unclear whether the narcissism is the chicken or the egg, said Dr. Longson, who is in private practice in Teaneck, N.J.

She found some trends suggesting that the kind of reality TV show might matter. People who watched voyeuristic shows such as the Kardashians or one of the "Real Housewives" iterations were more likely to feel that they had power over others and that they were more special than others. Watching skill-based reality shows such as "Survivor" also was associated with higher "special person" scores, but not as high as with watching the voyeuristic shows. The skill-based viewers also showed modestly increased scores for exhibitionism.

Watching educational reality shows, on the other hand, produced no statistically significant association with narcissistic traits. In fact, there were hints of a mild inverse relationship – watching the educational shows might be associated with less-narcissistic NPI scores, Dr. Longson said at the annual meeting of the American Psychiatric Association in San Francisco.

It’s difficult to determine if watching certain kinds of reality TV is a cause or a symptom of narcissism (or neither), but there’s enough here to warrant more research, she believes.

And it’s enough for Dr. Longson to offer some advice to her sister’s crowd and to society as a whole: "In our increasingly consumer-driven culture, we should take a moment and stop and consider what we’re consuming."

Dr. Longson reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Skipping breakfast triggered acute insulin resistance and elevated levels of free fatty acids in nine obese, nondiabetic women, compared with a day on which they ate breakfast in a randomized crossover trial.

If just 1 day of missing breakfast could do this, then skipping breakfast regularly over time may lead to further metabolic derangements, such as chronic insulin resistance and possible progression to type 2 diabetes mellitus, Dr. Elizabeth A. Thomas suggested.

The findings give clinicians one more tool to try to convince patients to eat a healthy breakfast, she said at the annual meeting of the Endocrine Society.

She and her associates studied the women on two separate days, approximately 1 month apart, and randomized them to receive breakfast or no breakfast at the first visit and the opposite at the second visit. They asked the women not to exercise prior to each visit and gave them a standardized dinner the night before the study day. Fasting laboratory measures were taken the morning of the study day, and 4 hours later, the participants were given a standardized lunch. The investigators took blood samples every 30 minutes after lunch for 3 hours and later gave them a standardized dinner.

Levels of insulin and glucose did not differ significantly between groups before lunch. Insulin and glucose levels were significantly higher after lunch on the days that the women skipped breakfast, representing acute insulin resistance, reported Dr. Thomas, an endocrinology fellow at the University of Colorado, Aurora.

Insulin levels rose significantly higher on the no-breakfast days, compared with after breakfast within 1 hour of the meal, and remained significantly higher at 2 hours. Similarly, the increase in glucose levels was significantly higher on the no-breakfast days within 1 hour of eating and remained significantly elevated, compared with levels on the breakfast days.

Free fatty acid levels were suppressed following breakfast, as would be expected, and thus were higher before lunch on days without breakfast. Both the total and incremental area under the curve (AUC) for free fatty acids after lunch were higher on the no-breakfast days, compared with breakfast days, suggesting that prelunch free fatty acid levels were not the cause of the increased AUC, she said.

Prelunch triglyceride levels were lower on no-breakfast days than on breakfast days. The total AUC for triglyceride levels after lunch was lower on no-breakfast days, compared with breakfast days, but the incremental AUC did not differ significantly between groups, suggesting that the prelunch triglyceride levels were driving the difference in total AUC, Dr. Thomas said.

Indirect calorimetry measures showed decreased energy expenditure on no-breakfast days and a significantly reduced respiratory quotient, which indicates greater fat oxidation, she said.

Previous epidemiologic and longitudinal studies have found associations between breakfast skipping and greater weight gain and risk for type 2 diabetes, but most of these were small studies focused on lean subjects, and none have shown a causal relationship, Dr. Thomas said. Few other short-term studies have assessed the effects of breakfast skipping on metabolic parameters and appetite.

In the study, the insulin total AUC was 12,322 microIU/mL x 180 minutes on no-breakfast days, compared with 8,882 microIU/mL x 180 minutes on breakfast days. The glucose total AUC was 20,775 vs. 18,126 mg/dL x 180 minutes on no-breakfast and breakfast days, respectively.

Prelunch free fatty acid levels on no-breakfast and breakfast days, respectively, were 705 vs. 287 microEq/L, and the total AUC for free fatty acids was 33,980 vs. 25,692 microEq/L x 180 minutes. The incremental AUC for free fatty acids was –92,980 vs. –26,008 microEq/L x 180 minutes. Prelunch triglyceride levels were 86 vs. 121 mg/dL on no-breakfast and breakfast days, respectively. The triglyceride total AUC was 17,352 vs. 24,060 mg/dL x 180 minutes on days without and with breakfast, respectively.

The women had a mean age of 29 years and a mean body mass index of 31 kg/m². Eight women said that they habitually eat breakfast. Dr. Thomas hopes to expand the study to 20 women and to include more women who habitually skip breakfast. She also plans to control for exercise in a future study.

The medical literature reports that roughly 10%-20% of Americans routinely skip breakfast, she said. Dr. Lisa Fish of the University of Minnesota, Minneapolis, who moderated a press briefing on Dr. Thomas’s study, said that many American breakfasts are high in carbohydrates and low in protein, and that eating a more balanced meal at the start of the day would be healthier.

Dr. Thomas reported having no financial disclosures. The study was funded by the Endocrine Fellows Foundation, the National Institutes of Health, and the Colorado Nutrition Obesity Research Center.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Skipping breakfast triggered acute insulin resistance and elevated levels of free fatty acids in nine obese, nondiabetic women, compared with a day on which they ate breakfast in a randomized crossover trial.

If just 1 day of missing breakfast could do this, then skipping breakfast regularly over time may lead to further metabolic derangements, such as chronic insulin resistance and possible progression to type 2 diabetes mellitus, Dr. Elizabeth A. Thomas suggested.

The findings give clinicians one more tool to try to convince patients to eat a healthy breakfast, she said at the annual meeting of the Endocrine Society.

She and her associates studied the women on two separate days, approximately 1 month apart, and randomized them to receive breakfast or no breakfast at the first visit and the opposite at the second visit. They asked the women not to exercise prior to each visit and gave them a standardized dinner the night before the study day. Fasting laboratory measures were taken the morning of the study day, and 4 hours later, the participants were given a standardized lunch. The investigators took blood samples every 30 minutes after lunch for 3 hours and later gave them a standardized dinner.

Levels of insulin and glucose did not differ significantly between groups before lunch. Insulin and glucose levels were significantly higher after lunch on the days that the women skipped breakfast, representing acute insulin resistance, reported Dr. Thomas, an endocrinology fellow at the University of Colorado, Aurora.

Insulin levels rose significantly higher on the no-breakfast days, compared with after breakfast within 1 hour of the meal, and remained significantly higher at 2 hours. Similarly, the increase in glucose levels was significantly higher on the no-breakfast days within 1 hour of eating and remained significantly elevated, compared with levels on the breakfast days.

Free fatty acid levels were suppressed following breakfast, as would be expected, and thus were higher before lunch on days without breakfast. Both the total and incremental area under the curve (AUC) for free fatty acids after lunch were higher on the no-breakfast days, compared with breakfast days, suggesting that prelunch free fatty acid levels were not the cause of the increased AUC, she said.

Prelunch triglyceride levels were lower on no-breakfast days than on breakfast days. The total AUC for triglyceride levels after lunch was lower on no-breakfast days, compared with breakfast days, but the incremental AUC did not differ significantly between groups, suggesting that the prelunch triglyceride levels were driving the difference in total AUC, Dr. Thomas said.

Indirect calorimetry measures showed decreased energy expenditure on no-breakfast days and a significantly reduced respiratory quotient, which indicates greater fat oxidation, she said.

Previous epidemiologic and longitudinal studies have found associations between breakfast skipping and greater weight gain and risk for type 2 diabetes, but most of these were small studies focused on lean subjects, and none have shown a causal relationship, Dr. Thomas said. Few other short-term studies have assessed the effects of breakfast skipping on metabolic parameters and appetite.

In the study, the insulin total AUC was 12,322 microIU/mL x 180 minutes on no-breakfast days, compared with 8,882 microIU/mL x 180 minutes on breakfast days. The glucose total AUC was 20,775 vs. 18,126 mg/dL x 180 minutes on no-breakfast and breakfast days, respectively.

Prelunch free fatty acid levels on no-breakfast and breakfast days, respectively, were 705 vs. 287 microEq/L, and the total AUC for free fatty acids was 33,980 vs. 25,692 microEq/L x 180 minutes. The incremental AUC for free fatty acids was –92,980 vs. –26,008 microEq/L x 180 minutes. Prelunch triglyceride levels were 86 vs. 121 mg/dL on no-breakfast and breakfast days, respectively. The triglyceride total AUC was 17,352 vs. 24,060 mg/dL x 180 minutes on days without and with breakfast, respectively.

The women had a mean age of 29 years and a mean body mass index of 31 kg/m². Eight women said that they habitually eat breakfast. Dr. Thomas hopes to expand the study to 20 women and to include more women who habitually skip breakfast. She also plans to control for exercise in a future study.

The medical literature reports that roughly 10%-20% of Americans routinely skip breakfast, she said. Dr. Lisa Fish of the University of Minnesota, Minneapolis, who moderated a press briefing on Dr. Thomas’s study, said that many American breakfasts are high in carbohydrates and low in protein, and that eating a more balanced meal at the start of the day would be healthier.

Dr. Thomas reported having no financial disclosures. The study was funded by the Endocrine Fellows Foundation, the National Institutes of Health, and the Colorado Nutrition Obesity Research Center.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Skipping breakfast triggered acute insulin resistance and elevated levels of free fatty acids in nine obese, nondiabetic women, compared with a day on which they ate breakfast in a randomized crossover trial.

If just 1 day of missing breakfast could do this, then skipping breakfast regularly over time may lead to further metabolic derangements, such as chronic insulin resistance and possible progression to type 2 diabetes mellitus, Dr. Elizabeth A. Thomas suggested.

The findings give clinicians one more tool to try to convince patients to eat a healthy breakfast, she said at the annual meeting of the Endocrine Society.

She and her associates studied the women on two separate days, approximately 1 month apart, and randomized them to receive breakfast or no breakfast at the first visit and the opposite at the second visit. They asked the women not to exercise prior to each visit and gave them a standardized dinner the night before the study day. Fasting laboratory measures were taken the morning of the study day, and 4 hours later, the participants were given a standardized lunch. The investigators took blood samples every 30 minutes after lunch for 3 hours and later gave them a standardized dinner.

Levels of insulin and glucose did not differ significantly between groups before lunch. Insulin and glucose levels were significantly higher after lunch on the days that the women skipped breakfast, representing acute insulin resistance, reported Dr. Thomas, an endocrinology fellow at the University of Colorado, Aurora.

Insulin levels rose significantly higher on the no-breakfast days, compared with after breakfast within 1 hour of the meal, and remained significantly higher at 2 hours. Similarly, the increase in glucose levels was significantly higher on the no-breakfast days within 1 hour of eating and remained significantly elevated, compared with levels on the breakfast days.

Free fatty acid levels were suppressed following breakfast, as would be expected, and thus were higher before lunch on days without breakfast. Both the total and incremental area under the curve (AUC) for free fatty acids after lunch were higher on the no-breakfast days, compared with breakfast days, suggesting that prelunch free fatty acid levels were not the cause of the increased AUC, she said.

Prelunch triglyceride levels were lower on no-breakfast days than on breakfast days. The total AUC for triglyceride levels after lunch was lower on no-breakfast days, compared with breakfast days, but the incremental AUC did not differ significantly between groups, suggesting that the prelunch triglyceride levels were driving the difference in total AUC, Dr. Thomas said.

Indirect calorimetry measures showed decreased energy expenditure on no-breakfast days and a significantly reduced respiratory quotient, which indicates greater fat oxidation, she said.

Previous epidemiologic and longitudinal studies have found associations between breakfast skipping and greater weight gain and risk for type 2 diabetes, but most of these were small studies focused on lean subjects, and none have shown a causal relationship, Dr. Thomas said. Few other short-term studies have assessed the effects of breakfast skipping on metabolic parameters and appetite.

In the study, the insulin total AUC was 12,322 microIU/mL x 180 minutes on no-breakfast days, compared with 8,882 microIU/mL x 180 minutes on breakfast days. The glucose total AUC was 20,775 vs. 18,126 mg/dL x 180 minutes on no-breakfast and breakfast days, respectively.

Prelunch free fatty acid levels on no-breakfast and breakfast days, respectively, were 705 vs. 287 microEq/L, and the total AUC for free fatty acids was 33,980 vs. 25,692 microEq/L x 180 minutes. The incremental AUC for free fatty acids was –92,980 vs. –26,008 microEq/L x 180 minutes. Prelunch triglyceride levels were 86 vs. 121 mg/dL on no-breakfast and breakfast days, respectively. The triglyceride total AUC was 17,352 vs. 24,060 mg/dL x 180 minutes on days without and with breakfast, respectively.

The women had a mean age of 29 years and a mean body mass index of 31 kg/m². Eight women said that they habitually eat breakfast. Dr. Thomas hopes to expand the study to 20 women and to include more women who habitually skip breakfast. She also plans to control for exercise in a future study.

The medical literature reports that roughly 10%-20% of Americans routinely skip breakfast, she said. Dr. Lisa Fish of the University of Minnesota, Minneapolis, who moderated a press briefing on Dr. Thomas’s study, said that many American breakfasts are high in carbohydrates and low in protein, and that eating a more balanced meal at the start of the day would be healthier.

Dr. Thomas reported having no financial disclosures. The study was funded by the Endocrine Fellows Foundation, the National Institutes of Health, and the Colorado Nutrition Obesity Research Center.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Symptoms improved significantly after 12 weeks of cognitive-behavioral therapy conducted via e-mail in a randomized, controlled trial in 62 adults with generalized anxiety disorder.

The trial randomized 69 patients who were diagnosed with generalized anxiety disorder via an hour-long online chat interview and who were not receiving any treatment. One group then participated in 12 weekly sessions of cognitive-behavioral therapy (CBT) by e-mail, and the control group received no treatment. Baseline scores on the Beck Anxiety Inventory (BAI) were approximately 42 in both groups.

At baseline, 35 patients started in the CBT group and 34, in the control group. At the end of 6 months there were 31 participants in each group. Among the 62 who completed the study, 43 were female, and 19 were male. The average age was 30.4 years in the CBT group and 29.8 years in the control group.

Among the 62 patients who completed 12 weeks of the study, only the e-mail CBT group had significantly improved anxiety scores after 12 weeks, and the results held steady at a 6-month follow-up online assessment, Dr. Nazanin Alavi reported at the annual meeting of the American Psychiatric Association.

The BAI score in the CBT group was 42 at the start, 19 after 12 weeks, and 20 after 6 months and in the control group, was 44 at the beginning, 43 after 12 weeks, and 44 after 6 months, said Dr. Alavi, a psychiatry resident at Queen’s University, Kingston, Ont. She reported the results at a press briefing and in a poster presentation at the meeting.

The findings suggest that CBT via e-mail may be a useful alternative when in-person interactions between patients and therapists are not possible. "Despite the proven short- and long-term efficacy of psychotherapy, it is not accessible to many people," Dr. Alavi said.

Barriers such as long waiting lists in urban areas or shortages of mental health providers in remote areas may prevent or delay people from getting help. Immigrants who do not share the prime language and cultural traditions of the dominant population may prefer working with a mental health provider from their home country, but those providers may be scarce in number and located geographically far from some patients. Online CBT may be a helpful adjunct in these settings, she said.

The current study, for example, enrolled Farsi-speaking patients of Persian background.

A future study should compare e-mail CBT with in-person CBT, Dr. Alavi added.

E-mail CBT is limited by the need for access to computers and the Internet, and therapists are unable to see or hear patients’ affects when communicating by e-mail. Because the interactions are asynchronous, a patient who has a question about slides or other therapeutic material presented one week may not receive an answer to questions until the next week’s session. On the other hand, Dr. Alavi noted, therapists can process a weekly e-mail session for one patient in approximately 20 minutes, and so can handle three patients in an hour, compared with one patient in an hour-long session in person or via virtual face-to-face online technology such as Skype.

The study excluded patients who had suicidal ideation or who were starting pharmacotherapy or psychotherapy. Patients randomized to the control group were told that they could seek psychotherapy elsewhere and were asked to inform the investigators if they did so; those who sought psychotherapy elsewhere were excluded from the analysis.

Dr. Alavi reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Symptoms improved significantly after 12 weeks of cognitive-behavioral therapy conducted via e-mail in a randomized, controlled trial in 62 adults with generalized anxiety disorder.

The trial randomized 69 patients who were diagnosed with generalized anxiety disorder via an hour-long online chat interview and who were not receiving any treatment. One group then participated in 12 weekly sessions of cognitive-behavioral therapy (CBT) by e-mail, and the control group received no treatment. Baseline scores on the Beck Anxiety Inventory (BAI) were approximately 42 in both groups.

At baseline, 35 patients started in the CBT group and 34, in the control group. At the end of 6 months there were 31 participants in each group. Among the 62 who completed the study, 43 were female, and 19 were male. The average age was 30.4 years in the CBT group and 29.8 years in the control group.

Among the 62 patients who completed 12 weeks of the study, only the e-mail CBT group had significantly improved anxiety scores after 12 weeks, and the results held steady at a 6-month follow-up online assessment, Dr. Nazanin Alavi reported at the annual meeting of the American Psychiatric Association.

The BAI score in the CBT group was 42 at the start, 19 after 12 weeks, and 20 after 6 months and in the control group, was 44 at the beginning, 43 after 12 weeks, and 44 after 6 months, said Dr. Alavi, a psychiatry resident at Queen’s University, Kingston, Ont. She reported the results at a press briefing and in a poster presentation at the meeting.

The findings suggest that CBT via e-mail may be a useful alternative when in-person interactions between patients and therapists are not possible. "Despite the proven short- and long-term efficacy of psychotherapy, it is not accessible to many people," Dr. Alavi said.

Barriers such as long waiting lists in urban areas or shortages of mental health providers in remote areas may prevent or delay people from getting help. Immigrants who do not share the prime language and cultural traditions of the dominant population may prefer working with a mental health provider from their home country, but those providers may be scarce in number and located geographically far from some patients. Online CBT may be a helpful adjunct in these settings, she said.

The current study, for example, enrolled Farsi-speaking patients of Persian background.

A future study should compare e-mail CBT with in-person CBT, Dr. Alavi added.

E-mail CBT is limited by the need for access to computers and the Internet, and therapists are unable to see or hear patients’ affects when communicating by e-mail. Because the interactions are asynchronous, a patient who has a question about slides or other therapeutic material presented one week may not receive an answer to questions until the next week’s session. On the other hand, Dr. Alavi noted, therapists can process a weekly e-mail session for one patient in approximately 20 minutes, and so can handle three patients in an hour, compared with one patient in an hour-long session in person or via virtual face-to-face online technology such as Skype.

The study excluded patients who had suicidal ideation or who were starting pharmacotherapy or psychotherapy. Patients randomized to the control group were told that they could seek psychotherapy elsewhere and were asked to inform the investigators if they did so; those who sought psychotherapy elsewhere were excluded from the analysis.

Dr. Alavi reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Symptoms improved significantly after 12 weeks of cognitive-behavioral therapy conducted via e-mail in a randomized, controlled trial in 62 adults with generalized anxiety disorder.

The trial randomized 69 patients who were diagnosed with generalized anxiety disorder via an hour-long online chat interview and who were not receiving any treatment. One group then participated in 12 weekly sessions of cognitive-behavioral therapy (CBT) by e-mail, and the control group received no treatment. Baseline scores on the Beck Anxiety Inventory (BAI) were approximately 42 in both groups.

At baseline, 35 patients started in the CBT group and 34, in the control group. At the end of 6 months there were 31 participants in each group. Among the 62 who completed the study, 43 were female, and 19 were male. The average age was 30.4 years in the CBT group and 29.8 years in the control group.

Among the 62 patients who completed 12 weeks of the study, only the e-mail CBT group had significantly improved anxiety scores after 12 weeks, and the results held steady at a 6-month follow-up online assessment, Dr. Nazanin Alavi reported at the annual meeting of the American Psychiatric Association.

The BAI score in the CBT group was 42 at the start, 19 after 12 weeks, and 20 after 6 months and in the control group, was 44 at the beginning, 43 after 12 weeks, and 44 after 6 months, said Dr. Alavi, a psychiatry resident at Queen’s University, Kingston, Ont. She reported the results at a press briefing and in a poster presentation at the meeting.

The findings suggest that CBT via e-mail may be a useful alternative when in-person interactions between patients and therapists are not possible. "Despite the proven short- and long-term efficacy of psychotherapy, it is not accessible to many people," Dr. Alavi said.

Barriers such as long waiting lists in urban areas or shortages of mental health providers in remote areas may prevent or delay people from getting help. Immigrants who do not share the prime language and cultural traditions of the dominant population may prefer working with a mental health provider from their home country, but those providers may be scarce in number and located geographically far from some patients. Online CBT may be a helpful adjunct in these settings, she said.

The current study, for example, enrolled Farsi-speaking patients of Persian background.

A future study should compare e-mail CBT with in-person CBT, Dr. Alavi added.

E-mail CBT is limited by the need for access to computers and the Internet, and therapists are unable to see or hear patients’ affects when communicating by e-mail. Because the interactions are asynchronous, a patient who has a question about slides or other therapeutic material presented one week may not receive an answer to questions until the next week’s session. On the other hand, Dr. Alavi noted, therapists can process a weekly e-mail session for one patient in approximately 20 minutes, and so can handle three patients in an hour, compared with one patient in an hour-long session in person or via virtual face-to-face online technology such as Skype.

The study excluded patients who had suicidal ideation or who were starting pharmacotherapy or psychotherapy. Patients randomized to the control group were told that they could seek psychotherapy elsewhere and were asked to inform the investigators if they did so; those who sought psychotherapy elsewhere were excluded from the analysis.

Dr. Alavi reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Neurobiological effects of trauma persist for years and might help survivors better handle future trauma or increase their risk of cardiovascular disease and other problems, three studies suggest.

One study assessed 34 adult survivors of Hurricane Katrina who were relocated to Oklahoma 22 months after the hurricane, and compared them with 34 control participants in Oklahoma who matched the survivors’ characteristics. A second study assessed nine adolescent survivors who were relocated 22 months after Hurricane Katrina and nine matched controls. The third study compared 60 adults who directly experienced the Oklahoma City bombing (84% of whom were injured) with matched controls 7 years after the bombing.

The results showed that autonomic, neuroendocrine, and immune system changes from trauma might last for years, even after emotional wounds have healed, Dr. Phebe M. Tucker reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The survivors and controls differed in mean arterial blood pressure, heart rate, variability of heart rate, and levels of cortisol, a regulatory substance that promotes the fight-or-flight response; interleukin-2 (IL-2), which protects against infection; and interleukin 6 (IL-6), which promotes inflammation).

Some of these changes might enhance a person’s fight-or-flight response, and so could prepare survivors for future disasters, but the health implications are unclear, she said. Previous studies have linked trauma to increased cardiovascular and other health problems, such as a tripling in the myocardial infarction rate at Tulane University in New Orleans after Hurricane Katrina. The physiologic changes seen in the current studies might contribute to that.

The current studies also found more short-term and long-term neurobiological changes in survivors with depression or posttraumatic stress disorder (PTSD), compared with survivors without depression or PTSD or control participants.

In the study of adult survivors of Hurricane Katrina, 35% of survivors and 12% of controls had PTSD. Baseline heart rates were significantly higher among survivors (81 beats per minute), compared with controls (75 beats per minute). Survivors with or without PTSD had significantly higher levels of IL-6, compared with control participants who did not have PTSD, reported Dr. Tucker, chair of psychiatry at the University of Oklahoma Health Sciences Center, Oklahoma City. She conducted the studies with Dr. David H. Tiller, also of the university.

Survivors’ baseline sympathetic (fight-or-flight) heart rate variability was significantly higher – approximately double – that of the control group. The protective, parasympathetic heart rate variability at rest was significantly lower than in controls. When participants were exposed to reminders of the hurricane, the controls showed a significantly greater reaction in the parasympathetic heart rate variability, compared with a flat response among survivors, she said.

"Overall, the adult Katrina survivors’ higher heart rates, decreased protective heart rate variability, and increased inflammatory IL-6 may increase their risk for heart disease," Dr. Tucker said.

The pilot study of 18 adolescent survivors and controls (average age 15 years) found significantly higher rates of symptoms for PTSD or depression among survivors. As might be expected from previous studies of trauma and PTSD, the survivors had lower levels of cortisol, and IL-2 levels correlated with cortisol levels, suggesting that survivors might have reduced immune protection and could be more susceptible to infection, she reported.

In contrast with the adult findings, however, higher PTSD symptoms in the adolescents correlated with lower levels of the inflammatory cytokine IL-6. This might be because the youths lacked the inflammatory changes seen in adults after trauma or the youths were more resilient in some ways, she speculated.

In the third study of the bombing survivors, mean PTSD and depression symptom severity scores were below clinically relevant levels 7 years after the bombing. The handful of survivors who still had PTSD had significantly higher cortisol levels, compared with non–PTSD survivors and controls.

When exposed to reminders of the bombing, the survivors showed greater increases in heart rate, systolic and diastolic blood pressures, and mean arterial pressure. "Autonomic reactivity may be a generalized long-term response" to trauma that’s independent of PTSD, she said.

Dr. Tucker reported having no financial disclosures.

sboschert@frontlinemedcom.com

Twitter @sherryboschert

SAN FRANCISCO – Neurobiological effects of trauma persist for years and might help survivors better handle future trauma or increase their risk of cardiovascular disease and other problems, three studies suggest.

One study assessed 34 adult survivors of Hurricane Katrina who were relocated to Oklahoma 22 months after the hurricane, and compared them with 34 control participants in Oklahoma who matched the survivors’ characteristics. A second study assessed nine adolescent survivors who were relocated 22 months after Hurricane Katrina and nine matched controls. The third study compared 60 adults who directly experienced the Oklahoma City bombing (84% of whom were injured) with matched controls 7 years after the bombing.

The results showed that autonomic, neuroendocrine, and immune system changes from trauma might last for years, even after emotional wounds have healed, Dr. Phebe M. Tucker reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The survivors and controls differed in mean arterial blood pressure, heart rate, variability of heart rate, and levels of cortisol, a regulatory substance that promotes the fight-or-flight response; interleukin-2 (IL-2), which protects against infection; and interleukin 6 (IL-6), which promotes inflammation).

Some of these changes might enhance a person’s fight-or-flight response, and so could prepare survivors for future disasters, but the health implications are unclear, she said. Previous studies have linked trauma to increased cardiovascular and other health problems, such as a tripling in the myocardial infarction rate at Tulane University in New Orleans after Hurricane Katrina. The physiologic changes seen in the current studies might contribute to that.

The current studies also found more short-term and long-term neurobiological changes in survivors with depression or posttraumatic stress disorder (PTSD), compared with survivors without depression or PTSD or control participants.

In the study of adult survivors of Hurricane Katrina, 35% of survivors and 12% of controls had PTSD. Baseline heart rates were significantly higher among survivors (81 beats per minute), compared with controls (75 beats per minute). Survivors with or without PTSD had significantly higher levels of IL-6, compared with control participants who did not have PTSD, reported Dr. Tucker, chair of psychiatry at the University of Oklahoma Health Sciences Center, Oklahoma City. She conducted the studies with Dr. David H. Tiller, also of the university.

Survivors’ baseline sympathetic (fight-or-flight) heart rate variability was significantly higher – approximately double – that of the control group. The protective, parasympathetic heart rate variability at rest was significantly lower than in controls. When participants were exposed to reminders of the hurricane, the controls showed a significantly greater reaction in the parasympathetic heart rate variability, compared with a flat response among survivors, she said.

"Overall, the adult Katrina survivors’ higher heart rates, decreased protective heart rate variability, and increased inflammatory IL-6 may increase their risk for heart disease," Dr. Tucker said.

The pilot study of 18 adolescent survivors and controls (average age 15 years) found significantly higher rates of symptoms for PTSD or depression among survivors. As might be expected from previous studies of trauma and PTSD, the survivors had lower levels of cortisol, and IL-2 levels correlated with cortisol levels, suggesting that survivors might have reduced immune protection and could be more susceptible to infection, she reported.

In contrast with the adult findings, however, higher PTSD symptoms in the adolescents correlated with lower levels of the inflammatory cytokine IL-6. This might be because the youths lacked the inflammatory changes seen in adults after trauma or the youths were more resilient in some ways, she speculated.

In the third study of the bombing survivors, mean PTSD and depression symptom severity scores were below clinically relevant levels 7 years after the bombing. The handful of survivors who still had PTSD had significantly higher cortisol levels, compared with non–PTSD survivors and controls.

When exposed to reminders of the bombing, the survivors showed greater increases in heart rate, systolic and diastolic blood pressures, and mean arterial pressure. "Autonomic reactivity may be a generalized long-term response" to trauma that’s independent of PTSD, she said.

Dr. Tucker reported having no financial disclosures.

sboschert@frontlinemedcom.com

Twitter @sherryboschert

SAN FRANCISCO – Neurobiological effects of trauma persist for years and might help survivors better handle future trauma or increase their risk of cardiovascular disease and other problems, three studies suggest.

One study assessed 34 adult survivors of Hurricane Katrina who were relocated to Oklahoma 22 months after the hurricane, and compared them with 34 control participants in Oklahoma who matched the survivors’ characteristics. A second study assessed nine adolescent survivors who were relocated 22 months after Hurricane Katrina and nine matched controls. The third study compared 60 adults who directly experienced the Oklahoma City bombing (84% of whom were injured) with matched controls 7 years after the bombing.

The results showed that autonomic, neuroendocrine, and immune system changes from trauma might last for years, even after emotional wounds have healed, Dr. Phebe M. Tucker reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The survivors and controls differed in mean arterial blood pressure, heart rate, variability of heart rate, and levels of cortisol, a regulatory substance that promotes the fight-or-flight response; interleukin-2 (IL-2), which protects against infection; and interleukin 6 (IL-6), which promotes inflammation).

Some of these changes might enhance a person’s fight-or-flight response, and so could prepare survivors for future disasters, but the health implications are unclear, she said. Previous studies have linked trauma to increased cardiovascular and other health problems, such as a tripling in the myocardial infarction rate at Tulane University in New Orleans after Hurricane Katrina. The physiologic changes seen in the current studies might contribute to that.

The current studies also found more short-term and long-term neurobiological changes in survivors with depression or posttraumatic stress disorder (PTSD), compared with survivors without depression or PTSD or control participants.

In the study of adult survivors of Hurricane Katrina, 35% of survivors and 12% of controls had PTSD. Baseline heart rates were significantly higher among survivors (81 beats per minute), compared with controls (75 beats per minute). Survivors with or without PTSD had significantly higher levels of IL-6, compared with control participants who did not have PTSD, reported Dr. Tucker, chair of psychiatry at the University of Oklahoma Health Sciences Center, Oklahoma City. She conducted the studies with Dr. David H. Tiller, also of the university.

Survivors’ baseline sympathetic (fight-or-flight) heart rate variability was significantly higher – approximately double – that of the control group. The protective, parasympathetic heart rate variability at rest was significantly lower than in controls. When participants were exposed to reminders of the hurricane, the controls showed a significantly greater reaction in the parasympathetic heart rate variability, compared with a flat response among survivors, she said.

"Overall, the adult Katrina survivors’ higher heart rates, decreased protective heart rate variability, and increased inflammatory IL-6 may increase their risk for heart disease," Dr. Tucker said.

The pilot study of 18 adolescent survivors and controls (average age 15 years) found significantly higher rates of symptoms for PTSD or depression among survivors. As might be expected from previous studies of trauma and PTSD, the survivors had lower levels of cortisol, and IL-2 levels correlated with cortisol levels, suggesting that survivors might have reduced immune protection and could be more susceptible to infection, she reported.

In contrast with the adult findings, however, higher PTSD symptoms in the adolescents correlated with lower levels of the inflammatory cytokine IL-6. This might be because the youths lacked the inflammatory changes seen in adults after trauma or the youths were more resilient in some ways, she speculated.

In the third study of the bombing survivors, mean PTSD and depression symptom severity scores were below clinically relevant levels 7 years after the bombing. The handful of survivors who still had PTSD had significantly higher cortisol levels, compared with non–PTSD survivors and controls.

When exposed to reminders of the bombing, the survivors showed greater increases in heart rate, systolic and diastolic blood pressures, and mean arterial pressure. "Autonomic reactivity may be a generalized long-term response" to trauma that’s independent of PTSD, she said.

Dr. Tucker reported having no financial disclosures.

sboschert@frontlinemedcom.com

Twitter @sherryboschert

SAN FRANCISCO – The more that teens reported being addicted to the Internet or their smartphones, the higher they scored on nine subscales of psychopathology and problematic behavior, based on a study of 195 adolescents.

Greater smartphone addiction correlated with an increased likelihood of somatic symptoms, withdrawal, depression or anxiety, thought problems, delinquency, attention problems, aggression, and internalizing or externalizing problems, Dr. Jonghun Lee reported at the annual meeting of the American Psychiatric Association.

He and his coinvestigators measured the severity of smartphone or computer Internet addiction using a 2010 smartphone addiction rating scale and the Kimberly Young Internet Addiction Test. They evaluated psychopathology scores using the Korean Youth Self Report, said Dr. Lee, professor of psychiatry at the Catholic University of Daegu (Korea).

Smartphone use in Korea has rocketed from uncommon to ubiquitous in the past 3 years. The number of smartphone users ballooned from approximately 470,000 in 2009 to nearly 33 million in 2012. In December 2010, 8% of Korean youths aged 5-19 years old used smartphones, but by June 2012 67% of that age group had smartphones, he said. The Korean Ministry of Public Administration and Security reported in 2012 that 11% of children and 8% of all ages were addicted to smartphones and 10% of children and 8% of all ages were addicted to the Internet, he added.

"We should try to screen for smartphone addiction as well as Internet/computer addiction in adolescents" to help manage the mental and physical effects of these digital addictions, Dr. Lee said.

He described one Korean news report that observed students on a lunch break at an 1,100-student middle school. Recess traditionally has been a time for kids to run and play between classes, but only five or six students were playing soccer during this lunch break. The rest were gathered in clusters by the bleachers next to the soccer field, looking at smartphones. Korean experts fear that the effects of smartphone use also are negatively affecting academic performance.

Previous studies have suggested that smartphone overuse or addiction to computers or the Internet correlated with an increased risk for depression, he said. Signs of smartphone addiction might include using the smartphone before bedtime or in the bathroom, and abnormal behavior after losing a smartphone, among other symptoms.

The current study is a preliminary one on the subject, and the findings were limited by its cross-sectional design, the use of only a self-report form for measuring psychopathology, and the lack of a standardized smartphone addiction scale at the start of the study, Dr. Lee said.

The many functions of smartphones, also called personal digital assistants, help make them addictive, he said. Almost anywhere, anytime, the user can access the Internet, retrieve information, play online games, take photos or videos, play music or videos, or access a global positioning system for navigation, among other features.

Dr. Lee reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – The more that teens reported being addicted to the Internet or their smartphones, the higher they scored on nine subscales of psychopathology and problematic behavior, based on a study of 195 adolescents.

Greater smartphone addiction correlated with an increased likelihood of somatic symptoms, withdrawal, depression or anxiety, thought problems, delinquency, attention problems, aggression, and internalizing or externalizing problems, Dr. Jonghun Lee reported at the annual meeting of the American Psychiatric Association.

He and his coinvestigators measured the severity of smartphone or computer Internet addiction using a 2010 smartphone addiction rating scale and the Kimberly Young Internet Addiction Test. They evaluated psychopathology scores using the Korean Youth Self Report, said Dr. Lee, professor of psychiatry at the Catholic University of Daegu (Korea).

Smartphone use in Korea has rocketed from uncommon to ubiquitous in the past 3 years. The number of smartphone users ballooned from approximately 470,000 in 2009 to nearly 33 million in 2012. In December 2010, 8% of Korean youths aged 5-19 years old used smartphones, but by June 2012 67% of that age group had smartphones, he said. The Korean Ministry of Public Administration and Security reported in 2012 that 11% of children and 8% of all ages were addicted to smartphones and 10% of children and 8% of all ages were addicted to the Internet, he added.

"We should try to screen for smartphone addiction as well as Internet/computer addiction in adolescents" to help manage the mental and physical effects of these digital addictions, Dr. Lee said.

He described one Korean news report that observed students on a lunch break at an 1,100-student middle school. Recess traditionally has been a time for kids to run and play between classes, but only five or six students were playing soccer during this lunch break. The rest were gathered in clusters by the bleachers next to the soccer field, looking at smartphones. Korean experts fear that the effects of smartphone use also are negatively affecting academic performance.

Previous studies have suggested that smartphone overuse or addiction to computers or the Internet correlated with an increased risk for depression, he said. Signs of smartphone addiction might include using the smartphone before bedtime or in the bathroom, and abnormal behavior after losing a smartphone, among other symptoms.

The current study is a preliminary one on the subject, and the findings were limited by its cross-sectional design, the use of only a self-report form for measuring psychopathology, and the lack of a standardized smartphone addiction scale at the start of the study, Dr. Lee said.

The many functions of smartphones, also called personal digital assistants, help make them addictive, he said. Almost anywhere, anytime, the user can access the Internet, retrieve information, play online games, take photos or videos, play music or videos, or access a global positioning system for navigation, among other features.

Dr. Lee reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – The more that teens reported being addicted to the Internet or their smartphones, the higher they scored on nine subscales of psychopathology and problematic behavior, based on a study of 195 adolescents.

Greater smartphone addiction correlated with an increased likelihood of somatic symptoms, withdrawal, depression or anxiety, thought problems, delinquency, attention problems, aggression, and internalizing or externalizing problems, Dr. Jonghun Lee reported at the annual meeting of the American Psychiatric Association.

He and his coinvestigators measured the severity of smartphone or computer Internet addiction using a 2010 smartphone addiction rating scale and the Kimberly Young Internet Addiction Test. They evaluated psychopathology scores using the Korean Youth Self Report, said Dr. Lee, professor of psychiatry at the Catholic University of Daegu (Korea).

Smartphone use in Korea has rocketed from uncommon to ubiquitous in the past 3 years. The number of smartphone users ballooned from approximately 470,000 in 2009 to nearly 33 million in 2012. In December 2010, 8% of Korean youths aged 5-19 years old used smartphones, but by June 2012 67% of that age group had smartphones, he said. The Korean Ministry of Public Administration and Security reported in 2012 that 11% of children and 8% of all ages were addicted to smartphones and 10% of children and 8% of all ages were addicted to the Internet, he added.

"We should try to screen for smartphone addiction as well as Internet/computer addiction in adolescents" to help manage the mental and physical effects of these digital addictions, Dr. Lee said.

He described one Korean news report that observed students on a lunch break at an 1,100-student middle school. Recess traditionally has been a time for kids to run and play between classes, but only five or six students were playing soccer during this lunch break. The rest were gathered in clusters by the bleachers next to the soccer field, looking at smartphones. Korean experts fear that the effects of smartphone use also are negatively affecting academic performance.

Previous studies have suggested that smartphone overuse or addiction to computers or the Internet correlated with an increased risk for depression, he said. Signs of smartphone addiction might include using the smartphone before bedtime or in the bathroom, and abnormal behavior after losing a smartphone, among other symptoms.

The current study is a preliminary one on the subject, and the findings were limited by its cross-sectional design, the use of only a self-report form for measuring psychopathology, and the lack of a standardized smartphone addiction scale at the start of the study, Dr. Lee said.

The many functions of smartphones, also called personal digital assistants, help make them addictive, he said. Almost anywhere, anytime, the user can access the Internet, retrieve information, play online games, take photos or videos, play music or videos, or access a global positioning system for navigation, among other features.

Dr. Lee reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Health care providers respond to patients’ physical problems differently, depending on whether or not the patient also has schizophrenia, a survey of 275 doctors and nurses suggested.

The investigators expected to find that the 62 psychiatrists in the study would treat patients more equitably regardless of mental illness, compared with the 55 primary care physicians, 91 primary care nurses, and 67 psychiatric nurses in the study, but that was not the case, Dr. Dinesh Mittal said at the annual meeting of the American Psychiatric Association.

Providers in each category were less likely to refer a hypothetical patient to a weight-reduction program if the patient had schizophrenia. They expected a schizophrenia patient to be less likely to adhere to treatment, less competent to make treatment decisions, and less likely to function well socially, compared with a patient without schizophrenia, Dr. Mittal and his associates found.

Those reactions are based on myths about people with schizophrenia, said Dr. Mittal, a staff psychiatrist for the Central Arkansas Veterans Healthcare System and associate professor of psychiatry at the University of Arkansas for Medical Sciences, Little Rock. The study "suggests that there’s a need for addressing bias" among health care professionals toward patients with mental illness, said Dr. Mittal, who was co-principal investigator of the study with Dr. Greer Sullivan.

The providers in the study, recruited from five Veterans Affairs (VA) medical centers, were asked to consider one of two nearly identical patient vignettes, except that one was a clinically stable person with schizophrenia and the other had no schizophrenia. The hypothetical patient was a 34-year-old male with hypertension, obesity, insomnia, and chronic back pain who was returning for a follow-up visit and seeking stronger medication for pain. He was taking naproxen and fluoxetine with no history of substance abuse. The patient worked in a VA cafeteria, attended church, and enjoyed fishing and reading magazines.

After reading the vignette, the participants answered questions about their clinical expectations, treatment decisions, and attitudes relative to the patient described. Because there are no scales to assess clinical expectations and treatment decisions relative to a given vignette, the investigators created scales using multiple questions about expected patient adherence to therapy, ability to understand educational materials, competence to manage health care and personal finances, social and vocational functioning, and the providers’ likelihood to involve the patient’s family in treatment.

The investigators also included single questions about whether or not the provider would refer the patient to programs for weight reduction or pain management, or for a sleep study.

The providers' self-reported likelihood of referring a patient with schizophrenia to a weight management program was 9% lower than for patients without schizophrenia, Dr. Mittal said at his poster presentation. The difference was statistically significant.

A previous study showed, however, that obese persons with serious mental illness benefit from weight reduction programs, he noted (N. Engl. J. Med. 2013;368:1594-602).

Provider scores rating the likelihood of patient adherence to treatment were significantly 6% lower for the schizophrenia patient than the patient without schizophrenia, which also reached significance. That’s despite World Health Organization data showing that the range of nonadherence rates in persons with schizophrenia is no different from those of persons with other chronic illnesses, Dr. Mittal said.

The health care providers rated the schizophrenia patient 17% less likely than the patient without schizophrenia to be functioning socially, a significant difference. A 2012 study found, however, that only about 25% of people with schizophrenia have poor long-term outcomes and lower function (Schizophr. Bull. 2012 Dec. 7 [doi:10.1093/schbull/sbs135]). "Seventy-five percent may not show functional decline similar to others without schizophrenia," Dr. Mittal said.

The patient with schizophrenia was considered 38% less competent to make treatment decisions, compared with the patient without schizophrenia, a significant difference. Previous data have shown, however, that people with schizophrenia are likely to have adequate decision-making capacity unless they are psychotic, Dr. Mittal said.

Providers were 20% more likely to say that they would include the patient’s family in treatment decisions if the patient had schizophrenia, compared with the patient without schizophrenia, again a significant difference. That might be good medical practice, or it could represent paternalistic attitudes held by providers toward people with schizophrenia, Dr. Mittal said.

The schizophrenia patient was less likely to be referred for a sleep study and slightly more likely to be referred to a pain-management program, compared with the patient without schizophrenia, but these differences in health care provider preferences did not reach statistical significance.

Only one variable differed significantly by specialty, provider type, and vignette type: Both psychiatrists and primary care nurses expected SMI patients to be less likely to read and understand educational materials than non-SMI patients. Mental health nurses, however, expected SMI patients to be more likely to read or understand educational materials than psychiatrists. Mental health nurses also expected SMI patients to be more likely to read or understand educational materials than PC nurses.

The investigators were inspired to do the current study by previous data suggesting that patients were less likely to be referred for a percutaneous transluminal coronary angioplasty (PTCA) if they had mental illness (approximately a 40% chance of PTCA) or substance abuse disorder (80%), compared with patients with neither mental illness nor substance abuse (nearly 100% referred), Dr. Mittal said.

They next plan to design an intervention aimed at decreasing bias and prejudice among health care providers toward people with serious mental illness, he said. Research also is needed to determine the extent to which stigmatized or negative views of mental illness might influence the quality of clinical care delivered.

The study was funded by the VA health care system research and development. Dr. Mittal reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Health care providers respond to patients’ physical problems differently, depending on whether or not the patient also has schizophrenia, a survey of 275 doctors and nurses suggested.

The investigators expected to find that the 62 psychiatrists in the study would treat patients more equitably regardless of mental illness, compared with the 55 primary care physicians, 91 primary care nurses, and 67 psychiatric nurses in the study, but that was not the case, Dr. Dinesh Mittal said at the annual meeting of the American Psychiatric Association.

Providers in each category were less likely to refer a hypothetical patient to a weight-reduction program if the patient had schizophrenia. They expected a schizophrenia patient to be less likely to adhere to treatment, less competent to make treatment decisions, and less likely to function well socially, compared with a patient without schizophrenia, Dr. Mittal and his associates found.

Those reactions are based on myths about people with schizophrenia, said Dr. Mittal, a staff psychiatrist for the Central Arkansas Veterans Healthcare System and associate professor of psychiatry at the University of Arkansas for Medical Sciences, Little Rock. The study "suggests that there’s a need for addressing bias" among health care professionals toward patients with mental illness, said Dr. Mittal, who was co-principal investigator of the study with Dr. Greer Sullivan.

The providers in the study, recruited from five Veterans Affairs (VA) medical centers, were asked to consider one of two nearly identical patient vignettes, except that one was a clinically stable person with schizophrenia and the other had no schizophrenia. The hypothetical patient was a 34-year-old male with hypertension, obesity, insomnia, and chronic back pain who was returning for a follow-up visit and seeking stronger medication for pain. He was taking naproxen and fluoxetine with no history of substance abuse. The patient worked in a VA cafeteria, attended church, and enjoyed fishing and reading magazines.

After reading the vignette, the participants answered questions about their clinical expectations, treatment decisions, and attitudes relative to the patient described. Because there are no scales to assess clinical expectations and treatment decisions relative to a given vignette, the investigators created scales using multiple questions about expected patient adherence to therapy, ability to understand educational materials, competence to manage health care and personal finances, social and vocational functioning, and the providers’ likelihood to involve the patient’s family in treatment.

The investigators also included single questions about whether or not the provider would refer the patient to programs for weight reduction or pain management, or for a sleep study.

The providers' self-reported likelihood of referring a patient with schizophrenia to a weight management program was 9% lower than for patients without schizophrenia, Dr. Mittal said at his poster presentation. The difference was statistically significant.

A previous study showed, however, that obese persons with serious mental illness benefit from weight reduction programs, he noted (N. Engl. J. Med. 2013;368:1594-602).

Provider scores rating the likelihood of patient adherence to treatment were significantly 6% lower for the schizophrenia patient than the patient without schizophrenia, which also reached significance. That’s despite World Health Organization data showing that the range of nonadherence rates in persons with schizophrenia is no different from those of persons with other chronic illnesses, Dr. Mittal said.

The health care providers rated the schizophrenia patient 17% less likely than the patient without schizophrenia to be functioning socially, a significant difference. A 2012 study found, however, that only about 25% of people with schizophrenia have poor long-term outcomes and lower function (Schizophr. Bull. 2012 Dec. 7 [doi:10.1093/schbull/sbs135]). "Seventy-five percent may not show functional decline similar to others without schizophrenia," Dr. Mittal said.

The patient with schizophrenia was considered 38% less competent to make treatment decisions, compared with the patient without schizophrenia, a significant difference. Previous data have shown, however, that people with schizophrenia are likely to have adequate decision-making capacity unless they are psychotic, Dr. Mittal said.

Providers were 20% more likely to say that they would include the patient’s family in treatment decisions if the patient had schizophrenia, compared with the patient without schizophrenia, again a significant difference. That might be good medical practice, or it could represent paternalistic attitudes held by providers toward people with schizophrenia, Dr. Mittal said.

The schizophrenia patient was less likely to be referred for a sleep study and slightly more likely to be referred to a pain-management program, compared with the patient without schizophrenia, but these differences in health care provider preferences did not reach statistical significance.

Only one variable differed significantly by specialty, provider type, and vignette type: Both psychiatrists and primary care nurses expected SMI patients to be less likely to read and understand educational materials than non-SMI patients. Mental health nurses, however, expected SMI patients to be more likely to read or understand educational materials than psychiatrists. Mental health nurses also expected SMI patients to be more likely to read or understand educational materials than PC nurses.

The investigators were inspired to do the current study by previous data suggesting that patients were less likely to be referred for a percutaneous transluminal coronary angioplasty (PTCA) if they had mental illness (approximately a 40% chance of PTCA) or substance abuse disorder (80%), compared with patients with neither mental illness nor substance abuse (nearly 100% referred), Dr. Mittal said.

They next plan to design an intervention aimed at decreasing bias and prejudice among health care providers toward people with serious mental illness, he said. Research also is needed to determine the extent to which stigmatized or negative views of mental illness might influence the quality of clinical care delivered.

The study was funded by the VA health care system research and development. Dr. Mittal reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Health care providers respond to patients’ physical problems differently, depending on whether or not the patient also has schizophrenia, a survey of 275 doctors and nurses suggested.

The investigators expected to find that the 62 psychiatrists in the study would treat patients more equitably regardless of mental illness, compared with the 55 primary care physicians, 91 primary care nurses, and 67 psychiatric nurses in the study, but that was not the case, Dr. Dinesh Mittal said at the annual meeting of the American Psychiatric Association.

Providers in each category were less likely to refer a hypothetical patient to a weight-reduction program if the patient had schizophrenia. They expected a schizophrenia patient to be less likely to adhere to treatment, less competent to make treatment decisions, and less likely to function well socially, compared with a patient without schizophrenia, Dr. Mittal and his associates found.

Those reactions are based on myths about people with schizophrenia, said Dr. Mittal, a staff psychiatrist for the Central Arkansas Veterans Healthcare System and associate professor of psychiatry at the University of Arkansas for Medical Sciences, Little Rock. The study "suggests that there’s a need for addressing bias" among health care professionals toward patients with mental illness, said Dr. Mittal, who was co-principal investigator of the study with Dr. Greer Sullivan.

The providers in the study, recruited from five Veterans Affairs (VA) medical centers, were asked to consider one of two nearly identical patient vignettes, except that one was a clinically stable person with schizophrenia and the other had no schizophrenia. The hypothetical patient was a 34-year-old male with hypertension, obesity, insomnia, and chronic back pain who was returning for a follow-up visit and seeking stronger medication for pain. He was taking naproxen and fluoxetine with no history of substance abuse. The patient worked in a VA cafeteria, attended church, and enjoyed fishing and reading magazines.

After reading the vignette, the participants answered questions about their clinical expectations, treatment decisions, and attitudes relative to the patient described. Because there are no scales to assess clinical expectations and treatment decisions relative to a given vignette, the investigators created scales using multiple questions about expected patient adherence to therapy, ability to understand educational materials, competence to manage health care and personal finances, social and vocational functioning, and the providers’ likelihood to involve the patient’s family in treatment.

The investigators also included single questions about whether or not the provider would refer the patient to programs for weight reduction or pain management, or for a sleep study.

The providers' self-reported likelihood of referring a patient with schizophrenia to a weight management program was 9% lower than for patients without schizophrenia, Dr. Mittal said at his poster presentation. The difference was statistically significant.

A previous study showed, however, that obese persons with serious mental illness benefit from weight reduction programs, he noted (N. Engl. J. Med. 2013;368:1594-602).

Provider scores rating the likelihood of patient adherence to treatment were significantly 6% lower for the schizophrenia patient than the patient without schizophrenia, which also reached significance. That’s despite World Health Organization data showing that the range of nonadherence rates in persons with schizophrenia is no different from those of persons with other chronic illnesses, Dr. Mittal said.

The health care providers rated the schizophrenia patient 17% less likely than the patient without schizophrenia to be functioning socially, a significant difference. A 2012 study found, however, that only about 25% of people with schizophrenia have poor long-term outcomes and lower function (Schizophr. Bull. 2012 Dec. 7 [doi:10.1093/schbull/sbs135]). "Seventy-five percent may not show functional decline similar to others without schizophrenia," Dr. Mittal said.

The patient with schizophrenia was considered 38% less competent to make treatment decisions, compared with the patient without schizophrenia, a significant difference. Previous data have shown, however, that people with schizophrenia are likely to have adequate decision-making capacity unless they are psychotic, Dr. Mittal said.

Providers were 20% more likely to say that they would include the patient’s family in treatment decisions if the patient had schizophrenia, compared with the patient without schizophrenia, again a significant difference. That might be good medical practice, or it could represent paternalistic attitudes held by providers toward people with schizophrenia, Dr. Mittal said.

The schizophrenia patient was less likely to be referred for a sleep study and slightly more likely to be referred to a pain-management program, compared with the patient without schizophrenia, but these differences in health care provider preferences did not reach statistical significance.

Only one variable differed significantly by specialty, provider type, and vignette type: Both psychiatrists and primary care nurses expected SMI patients to be less likely to read and understand educational materials than non-SMI patients. Mental health nurses, however, expected SMI patients to be more likely to read or understand educational materials than psychiatrists. Mental health nurses also expected SMI patients to be more likely to read or understand educational materials than PC nurses.

The investigators were inspired to do the current study by previous data suggesting that patients were less likely to be referred for a percutaneous transluminal coronary angioplasty (PTCA) if they had mental illness (approximately a 40% chance of PTCA) or substance abuse disorder (80%), compared with patients with neither mental illness nor substance abuse (nearly 100% referred), Dr. Mittal said.

They next plan to design an intervention aimed at decreasing bias and prejudice among health care providers toward people with serious mental illness, he said. Research also is needed to determine the extent to which stigmatized or negative views of mental illness might influence the quality of clinical care delivered.

The study was funded by the VA health care system research and development. Dr. Mittal reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Childhood neglect correlated with impaired capacity for close social relationships as an adult in a study of 114 nonpsychotic psychiatric inpatients.

The difficulty for patients with a history of childhood neglect centered more in maintaining than in starting close social relationships as adults, Thachell Tanis and Lisa J. Cohen, Ph.D., reported in a press briefing and a poster presentation at the annual meeting of the American Psychiatric Association.

The study used separate clinical self-report surveys to assess patients’ childhood histories and adult relational capacity. The Multidimensional Neglectful Behavior Scale assessed emotional, physical, cognitive, and supervisory neglect in the patients’ past. Patients also completed the relational domain of the Severity Indices of Personality Problems to assess capacity for intimacy or enduring relationships and the ability to feel recognized in relationships.

Each type of neglect significantly and negatively affected each facet in the relational domain. "Everything correlated with everything," said Ms. Tanis, a doctoral student at City College of New York.

The deficits were most striking in patients’ capacity for enduring relationships, said Dr. Cohen, professor of clinical psychiatry and behavioral sciences at Albert Einstein College of Medicine, New York. Childhood neglect as a whole, for example, correlated with an 81% greater negative effect on adult capacity for enduring relationships, compared with the negative effect on capacity for intimacy.

The cohort was 57% female, with a mean age of 39 years. Psychiatric diagnoses included depression in 55%, substance use disorder in 20%, bipolar disorder in 12%, anxiety in 10%, psychosis in 1%, and other diagnoses in 3%. The cohort was 44% white, 28% Hispanic, 16% black, 6% multiracial, 5% Asian, and 2% other ethnicities. The percentages total more than 100% because of rounding.

Prior studies have well documented the adverse effects of more dramatic forms of childhood maltreatment. Physical and sexual abuses in childhood, for example, have been associated with adult depression, eating disorders, and personality disorders, Dr. Cohen said. Only in recent years have mental health providers recognized the importance of less dramatic forms of childhood maltreatment, such as emotional abuse and neglect, and begun to study those issues.

The topic deserves further exploration, she added, because identifying these impairments in people with histories of childhood neglect might lead to better case conceptualization and possibly better treatment.

"You really do want to pay attention to your patients’ history of childhood neglect," Dr. Cohen said. "There may be more subtle types of maltreatment that have pernicious effects over time." If there is a history of neglect in childhood, pay attention not only to the patient’s ability to engage in relationships but the ability to maintain such relationships over time, she added.

The study was limited by using retrospective, self-report measures and its focus on inpatients, which might restrict the generalizability of the results.

The investigators reported having no financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – The anesthetic ketamine produced a significant and rapid antidepressant effect in a randomized, blinded, proof-of-concept study in *72 patients with treatment-resistant depression.

Within 24 hours, 64% of patients given an intravenous infusion of ketamine (47 patients) showed a response, compared with 28% of patients who showed a response in a control group given the anesthetic midazolam (25 patients), which mimics the anesthetic effects of ketamine but without any antidepressant effects, Dr. James W. Murrough and his associates reported.

Patients were assessed for depression before the infusion, 24 hours later, and again at days 2, 3 and 7 using the Montgomery-Asberg Depression Scale (MADRS). The ketamine group showed sustained improvement in MADRS scores up to a week after the infusion, Dr. Murrough said during a press briefing at the annual meeting of the American Psychiatric Association.

Ketamine is not approved to treat depression, and it’s premature to say that it should be, he noted. Data are needed on the efficacy and safety of taking ketamine over time, among other research questions, said Dr. Murrough of the departments of psychiatry and neuroscience at Mount Sinai School of Medicine, New York. Previous studies had suggested that ketamine may have a rapid antidepressant effect in treatment-resistant depression, but those studies were limited by small sample sizes, single-site cohorts, and other limitations.

Patients were randomized 2:1 to receive either 0.5 mg/kg of ketamine or 0.045 mg/kg of midazolam over 40 minutes. The patients were supervised and monitored by an anesthesiologist and spent the night on the clinical research unit.

The MADRS scores before treatment were approximately 32 in both groups. Within 24 hours, the primary endpoint, MADRS scores were approximately 16 in the ketamine group, a significant improvement, compared with 22 in the midazolam group, a nonsignificant change from baseline. Among secondary endpoints, MADRS scores held steady in both groups on days 2 and 3. By day 7, MADRS scores were approximately 18 in the ketamine group and 24 in the midazolam group, with ketamine’s effect no longer being statistically significant.

Dr. Murrough acknowledged that some psychiatrists use ketamine off label for patients with severe, refractory depression. His institution does not do so outside of trials and "we don’t recommend it," he said.

Ketamine is a drug of abuse on the streets, though usually in doses much higher than the dose in the study, he added. When chronically abused, ketamine can cause cognitive problems and schizoid effects, prior reports have suggested. A long history of ketamine use in anesthesia, however, shows that it is safe when used short-term in small doses under close medical supervision, he said. Data are needed to assess its safety beyond those parameters.

Future studies should look at the biomarkers and mechanisms of action when using ketamine to treat depression, its long-term safety and efficacy, and novel therapeutic targets.

Dr. Murrough reported research funding from the National Institutes of Health, the National Alliance for Research on Schizophrenia and Affective Disorders, the American Foundation for Suicide Prevention, Janssen Pharmaceuticals, Avanir Pharmaceuticals, and Evotec/Roche. If ketamine were to be approved to treat depression, his institution and one of its deans could benefit financially.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

 *This article was updated on 5/22/13.

SAN FRANCISCO – When considering statin therapy for an otherwise healthy patient with elevated cholesterol levels, count the number of cardiovascular risk factors present, Dr. Matthew Sorrentino said.

Even when no single risk factor is way out of line, a "clustering of risk factors" can help identify which patients might most benefit from statin therapy – even if they’re low risk according to Framingham Heart Study criteria or other risk assessment tools.

"It’s really the summation of all of these risk factors together that puts a patient at increased risk," Dr. Sorrentino said at the annual meeting of the American College of Physicians.

He was persuaded by an analysis by other investigators of data from all participants in the Framingham study who had no cardiovascular disease at age 50 years. The lifetime risk for developing cardiovascular disease increased with the number of elevated or major risk factors, from an optimal rate of 5% in men to a rate of 69% in those with two major risk factors, and in women from an optimal rate of 8% to 50% in those with two major risk factors (Circulation 2006;113:791-8).

Dr. Sorrentino gave the example of a patient, a 66-year-old woman, who says she’s worried about her health but has no cardiovascular symptoms. She smokes a few cigarettes a day and has been told in the past that she has borderline or mildly elevated blood pressure. On examination, her blood pressure is 139/92 mm Hg; her body mass index is 30 kg/m²; and fasting lipid results report total cholesterol of 222 mg/dL, a high-density lipoprotein (HDL) level of 42 mg/dL, a triglyceride level of 155 mg/dL, and a low-density lipoprotein (LDL) level of 149 mg/dL*. In sum, she meets three of the five criteria for metabolic syndrome.

By Framingham criteria, she is considered low risk, with an 8% risk for developing cardiovascular disease within 10 years, Dr. Sorrentino noted. But with her cigarette smoking, hypertension, and low HDL – in addition to her elevated LDL level – she has two or more major risk factors, so her lifetime risk for cardiovascular disease is 50%, he said.

"There’s been a lot more interest in thinking about global or lifetime risk," said Dr. Sorrentino, professor of medicine at the University of Chicago. "This can be one way of looking at low-risk patients."

There is some evidence that treating low-risk patients with statins can reduce cardiovascular disease. The best, though controversial, study on the subject was the randomized JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) trial, which found a 44% relative reduction in risk for cardiovascular disease over 5 years in patients treated with the statin, compared with placebo. The study calculated that 25 patients would need to be treated to prevent one myocardial infarction, stroke, revascularization procedure, or cardiovascular death over 5 years (N. Engl. J. Med. 2008;359:2195-2207).

That number needed to treat is similar to findings from two separate primary prevention trials using a statin, and it’s lower than the number needed to treat in many trials of standard blood pressure medications or low-dose aspirin, Dr. Sorrentino said.

Criticism of the JUPITER trial rested on whether it focused on a truly low-risk cohort. Approximately 40% of participants had metabolic syndrome, and 15% smoked, Dr. Sorrentino noted.

That’s why tallying the number of risk factors, as used in the 2008 analysis of lifetime risk, "will be better able to distinguish which low-risk patients would be worthwhile to consider treating," he said.

Dr. Sorrentino has been a speaker for Takeda Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 6/28/2013: An earlier version of this story incorrectly reported the hypothetical patient's LDL level.

SAN FRANCISCO – When considering statin therapy for an otherwise healthy patient with elevated cholesterol levels, count the number of cardiovascular risk factors present, Dr. Matthew Sorrentino said.

Even when no single risk factor is way out of line, a "clustering of risk factors" can help identify which patients might most benefit from statin therapy – even if they’re low risk according to Framingham Heart Study criteria or other risk assessment tools.

"It’s really the summation of all of these risk factors together that puts a patient at increased risk," Dr. Sorrentino said at the annual meeting of the American College of Physicians.

He was persuaded by an analysis by other investigators of data from all participants in the Framingham study who had no cardiovascular disease at age 50 years. The lifetime risk for developing cardiovascular disease increased with the number of elevated or major risk factors, from an optimal rate of 5% in men to a rate of 69% in those with two major risk factors, and in women from an optimal rate of 8% to 50% in those with two major risk factors (Circulation 2006;113:791-8).

Dr. Sorrentino gave the example of a patient, a 66-year-old woman, who says she’s worried about her health but has no cardiovascular symptoms. She smokes a few cigarettes a day and has been told in the past that she has borderline or mildly elevated blood pressure. On examination, her blood pressure is 139/92 mm Hg; her body mass index is 30 kg/m²; and fasting lipid results report total cholesterol of 222 mg/dL, a high-density lipoprotein (HDL) level of 42 mg/dL, a triglyceride level of 155 mg/dL, and a low-density lipoprotein (LDL) level of 149 mg/dL*. In sum, she meets three of the five criteria for metabolic syndrome.

By Framingham criteria, she is considered low risk, with an 8% risk for developing cardiovascular disease within 10 years, Dr. Sorrentino noted. But with her cigarette smoking, hypertension, and low HDL – in addition to her elevated LDL level – she has two or more major risk factors, so her lifetime risk for cardiovascular disease is 50%, he said.

"There’s been a lot more interest in thinking about global or lifetime risk," said Dr. Sorrentino, professor of medicine at the University of Chicago. "This can be one way of looking at low-risk patients."

There is some evidence that treating low-risk patients with statins can reduce cardiovascular disease. The best, though controversial, study on the subject was the randomized JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) trial, which found a 44% relative reduction in risk for cardiovascular disease over 5 years in patients treated with the statin, compared with placebo. The study calculated that 25 patients would need to be treated to prevent one myocardial infarction, stroke, revascularization procedure, or cardiovascular death over 5 years (N. Engl. J. Med. 2008;359:2195-2207).

That number needed to treat is similar to findings from two separate primary prevention trials using a statin, and it’s lower than the number needed to treat in many trials of standard blood pressure medications or low-dose aspirin, Dr. Sorrentino said.

Criticism of the JUPITER trial rested on whether it focused on a truly low-risk cohort. Approximately 40% of participants had metabolic syndrome, and 15% smoked, Dr. Sorrentino noted.

That’s why tallying the number of risk factors, as used in the 2008 analysis of lifetime risk, "will be better able to distinguish which low-risk patients would be worthwhile to consider treating," he said.

Dr. Sorrentino has been a speaker for Takeda Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 6/28/2013: An earlier version of this story incorrectly reported the hypothetical patient's LDL level.

SAN FRANCISCO – When considering statin therapy for an otherwise healthy patient with elevated cholesterol levels, count the number of cardiovascular risk factors present, Dr. Matthew Sorrentino said.

Even when no single risk factor is way out of line, a "clustering of risk factors" can help identify which patients might most benefit from statin therapy – even if they’re low risk according to Framingham Heart Study criteria or other risk assessment tools.

"It’s really the summation of all of these risk factors together that puts a patient at increased risk," Dr. Sorrentino said at the annual meeting of the American College of Physicians.

He was persuaded by an analysis by other investigators of data from all participants in the Framingham study who had no cardiovascular disease at age 50 years. The lifetime risk for developing cardiovascular disease increased with the number of elevated or major risk factors, from an optimal rate of 5% in men to a rate of 69% in those with two major risk factors, and in women from an optimal rate of 8% to 50% in those with two major risk factors (Circulation 2006;113:791-8).

Dr. Sorrentino gave the example of a patient, a 66-year-old woman, who says she’s worried about her health but has no cardiovascular symptoms. She smokes a few cigarettes a day and has been told in the past that she has borderline or mildly elevated blood pressure. On examination, her blood pressure is 139/92 mm Hg; her body mass index is 30 kg/m²; and fasting lipid results report total cholesterol of 222 mg/dL, a high-density lipoprotein (HDL) level of 42 mg/dL, a triglyceride level of 155 mg/dL, and a low-density lipoprotein (LDL) level of 149 mg/dL*. In sum, she meets three of the five criteria for metabolic syndrome.

By Framingham criteria, she is considered low risk, with an 8% risk for developing cardiovascular disease within 10 years, Dr. Sorrentino noted. But with her cigarette smoking, hypertension, and low HDL – in addition to her elevated LDL level – she has two or more major risk factors, so her lifetime risk for cardiovascular disease is 50%, he said.

"There’s been a lot more interest in thinking about global or lifetime risk," said Dr. Sorrentino, professor of medicine at the University of Chicago. "This can be one way of looking at low-risk patients."

There is some evidence that treating low-risk patients with statins can reduce cardiovascular disease. The best, though controversial, study on the subject was the randomized JUPITER (Justification for the Use of Statins in Primary Prevention: an Intervention Trial Evaluating Rosuvastatin) trial, which found a 44% relative reduction in risk for cardiovascular disease over 5 years in patients treated with the statin, compared with placebo. The study calculated that 25 patients would need to be treated to prevent one myocardial infarction, stroke, revascularization procedure, or cardiovascular death over 5 years (N. Engl. J. Med. 2008;359:2195-2207).

That number needed to treat is similar to findings from two separate primary prevention trials using a statin, and it’s lower than the number needed to treat in many trials of standard blood pressure medications or low-dose aspirin, Dr. Sorrentino said.

Criticism of the JUPITER trial rested on whether it focused on a truly low-risk cohort. Approximately 40% of participants had metabolic syndrome, and 15% smoked, Dr. Sorrentino noted.

That’s why tallying the number of risk factors, as used in the 2008 analysis of lifetime risk, "will be better able to distinguish which low-risk patients would be worthwhile to consider treating," he said.

Dr. Sorrentino has been a speaker for Takeda Pharmaceuticals.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

*Correction, 6/28/2013: An earlier version of this story incorrectly reported the hypothetical patient's LDL level.