APA 2013

NEW YORK – Selecting patients according to genotype and repurposing existing drugs for use in combination with drugs that enhance psychosocial interventions are among the new therapeutic opportunities in treating schizophrenia, Dr. Donald C. Goff said in an interview during the annual meeting of the American Psychiatric Association.

In this video, Dr. Goff of the Nathan Kline Institute for Psychiatric Research at New York University also discusses how combining drugs with psychosocial interventions can lead to areas of growth.

NEW YORK – Selecting patients according to genotype and repurposing existing drugs for use in combination with drugs that enhance psychosocial interventions are among the new therapeutic opportunities in treating schizophrenia, Dr. Donald C. Goff said in an interview during the annual meeting of the American Psychiatric Association.

In this video, Dr. Goff of the Nathan Kline Institute for Psychiatric Research at New York University also discusses how combining drugs with psychosocial interventions can lead to areas of growth.

NEW YORK – Selecting patients according to genotype and repurposing existing drugs for use in combination with drugs that enhance psychosocial interventions are among the new therapeutic opportunities in treating schizophrenia, Dr. Donald C. Goff said in an interview during the annual meeting of the American Psychiatric Association.

In this video, Dr. Goff of the Nathan Kline Institute for Psychiatric Research at New York University also discusses how combining drugs with psychosocial interventions can lead to areas of growth.

SAN FRANCISCO – A new type of scale for determining remission from depression performed well, compared with conventional measures in a study of 153 outpatients being treated for depression.

At baseline and after 3-4 months of treatment, patients completed the experimental Remission From Depression Questionnaire (RDQ) and the commonly used Quick Inventory of Depressive Symptomatology (QIDS). They were assessed using the 17-item Hamilton Depression Rating Scale (HAM-D). The QIDS and HAM-D focus on symptomatology, while the 41-item RDQ is a broader measure that includes other factors that patients have identified in previous studies as being important elements of remission, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

The effect size for all three scales were the same, meaning that the three tools were equally sensitive to change in depression, reported Dr. Zimmerman of Brown University, Providence, R.I.

Each of the seven subscales of the RDQ were sensitive to change, including subscales for symptoms of depression, other symptoms (such as anxiety or irritability), coping ability, positive mental health, functioning, life satisfaction, and general sense of well-being.

The RDQ scores were associated with self-perceived remission even after controlling for QIDS scores. In contrast, QIDS scores were associated with self-perceived remission, but not after controlling for the RDQ scores. "The RDQ is picking up variance in whether or not patients believe they are in remission above and beyond that accounted for by symptoms alone," said Dr. Zimmerman, also director of outpatient psychiatry at Rhode Island Hospital, Providence.

Historically, studies have found wide variability in the definition of remission from depression and in the terms used to describe it. A 1991 consensus conference defined remission as a score of 7 or less on the 17-item HAM-D. One of the limits of this and other definitions of remission is that they are completely symptom based with no consideration of other factors that might be important in determining how patients are doing during treatment, he said.

Dr. Zimmerman and his associates have been studying a broader concept of depression remission in studies over the past decade. "Just what this field needs – another measure to assess depression, because there aren’t enough of them already," he said sarcastically.

They initially surveyed 535 depressed outpatients to find out what they consider to be important aspects in determining remission. Among the 16 items they rated, symptom resolution didn’t make the top 4. The top factors rated by patients as important were the presence of positive mental health (selected by 77% of participants), feeling like one’s usual, normal self (76%); return to one’s usual level of functioning (74%); and feeling in emotional control (72%). When asked to choose the most important factor determining remission, 17% chose the presence of positive mental health, 14% chose feeling like one’s usual self, 11% picked a general sense of well-being, and only 10% pointed to the absence of symptoms of depression (Am. J. Psychiatry 2006;163:148-50).

"There seems to be a disconnect between what researchers have been doing all these years, which is defining remission purely in symptom terms, and what patients say are the most important considerations that they have in determining whether or not they’re in remission," he said.

Dr. Zimmerman and his associates next surveyed 514 outpatients being treated for major depressive disorder. They found that patients’ ratings of the severity of their depression, how much their symptoms have interfered with their lives or caused them difficulties, and their overall quality of life were significantly and independently associated with their view of whether or not they were in remission. (J. Psychiatr. Res. 2008;42:797-801).

The findings of these first two studies and subsequent focus groups led the investigators to develop the RDQ. In a study of 102 depressed outpatients, patients felt the RDQ was more accurate than was the symptom-based QIDS in assessing their goals and progress in treatment, and they preferred the RDQ, Dr. Zimmerman said (Ann. Clin. Psych. 2011;23:208-12).

He and his associates tested the RDQ’s reliability and validity in a study of 274 depressed outpatients in ongoing treatment, 60 of whom completed the RDQ twice to assess reliability. Patients filled out the RDQ and the QIDS, and were rated on the 17-item HAM-D and other measures. The RDQ proved to be reliable, with good internal consistency. Approximately 50% of patients were in self-reported remission according to the various measures. After researchers controlled for depression symptom severity, the RDQ identified patients who considered themselves to be in remission for reasons above and beyond symptoms status (J. Psychiatr. Res. 2013;47:78-82).

"It was capturing something unique" that the symptom-based QIDS and HAM-D scores missed, Dr. Zimmerman said. "Depressed patients’ perspective of remission goes beyond symptom resolution."

He is hopeful that the concept of remission is evolving, because outcomes in treatment trials increasingly are not being measured just in terms of symptom status alone. Investigators have begun to look at aspects of function and, less frequently, at quality of life, he said.

Dr. Zimmerman hopes to study whether a broader-based measure of remission, such as the RDQ, better predicts which patients are likely to relapse, compared with conventional remission measures. Another study could look at whether the RDQ is a superior outcome measure when treatment de-emphasizes symptomatic improvement, and instead focuses on functional improvement and quality of life, he said.

Dr. Zimmerman’s research was funded by Eli Lilly. He also reported financial associations with Bristol-Myers Squibb.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – A new type of scale for determining remission from depression performed well, compared with conventional measures in a study of 153 outpatients being treated for depression.

At baseline and after 3-4 months of treatment, patients completed the experimental Remission From Depression Questionnaire (RDQ) and the commonly used Quick Inventory of Depressive Symptomatology (QIDS). They were assessed using the 17-item Hamilton Depression Rating Scale (HAM-D). The QIDS and HAM-D focus on symptomatology, while the 41-item RDQ is a broader measure that includes other factors that patients have identified in previous studies as being important elements of remission, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

The effect size for all three scales were the same, meaning that the three tools were equally sensitive to change in depression, reported Dr. Zimmerman of Brown University, Providence, R.I.

Each of the seven subscales of the RDQ were sensitive to change, including subscales for symptoms of depression, other symptoms (such as anxiety or irritability), coping ability, positive mental health, functioning, life satisfaction, and general sense of well-being.

The RDQ scores were associated with self-perceived remission even after controlling for QIDS scores. In contrast, QIDS scores were associated with self-perceived remission, but not after controlling for the RDQ scores. "The RDQ is picking up variance in whether or not patients believe they are in remission above and beyond that accounted for by symptoms alone," said Dr. Zimmerman, also director of outpatient psychiatry at Rhode Island Hospital, Providence.

Historically, studies have found wide variability in the definition of remission from depression and in the terms used to describe it. A 1991 consensus conference defined remission as a score of 7 or less on the 17-item HAM-D. One of the limits of this and other definitions of remission is that they are completely symptom based with no consideration of other factors that might be important in determining how patients are doing during treatment, he said.

Dr. Zimmerman and his associates have been studying a broader concept of depression remission in studies over the past decade. "Just what this field needs – another measure to assess depression, because there aren’t enough of them already," he said sarcastically.

They initially surveyed 535 depressed outpatients to find out what they consider to be important aspects in determining remission. Among the 16 items they rated, symptom resolution didn’t make the top 4. The top factors rated by patients as important were the presence of positive mental health (selected by 77% of participants), feeling like one’s usual, normal self (76%); return to one’s usual level of functioning (74%); and feeling in emotional control (72%). When asked to choose the most important factor determining remission, 17% chose the presence of positive mental health, 14% chose feeling like one’s usual self, 11% picked a general sense of well-being, and only 10% pointed to the absence of symptoms of depression (Am. J. Psychiatry 2006;163:148-50).

"There seems to be a disconnect between what researchers have been doing all these years, which is defining remission purely in symptom terms, and what patients say are the most important considerations that they have in determining whether or not they’re in remission," he said.

Dr. Zimmerman and his associates next surveyed 514 outpatients being treated for major depressive disorder. They found that patients’ ratings of the severity of their depression, how much their symptoms have interfered with their lives or caused them difficulties, and their overall quality of life were significantly and independently associated with their view of whether or not they were in remission. (J. Psychiatr. Res. 2008;42:797-801).

The findings of these first two studies and subsequent focus groups led the investigators to develop the RDQ. In a study of 102 depressed outpatients, patients felt the RDQ was more accurate than was the symptom-based QIDS in assessing their goals and progress in treatment, and they preferred the RDQ, Dr. Zimmerman said (Ann. Clin. Psych. 2011;23:208-12).

He and his associates tested the RDQ’s reliability and validity in a study of 274 depressed outpatients in ongoing treatment, 60 of whom completed the RDQ twice to assess reliability. Patients filled out the RDQ and the QIDS, and were rated on the 17-item HAM-D and other measures. The RDQ proved to be reliable, with good internal consistency. Approximately 50% of patients were in self-reported remission according to the various measures. After researchers controlled for depression symptom severity, the RDQ identified patients who considered themselves to be in remission for reasons above and beyond symptoms status (J. Psychiatr. Res. 2013;47:78-82).

"It was capturing something unique" that the symptom-based QIDS and HAM-D scores missed, Dr. Zimmerman said. "Depressed patients’ perspective of remission goes beyond symptom resolution."

He is hopeful that the concept of remission is evolving, because outcomes in treatment trials increasingly are not being measured just in terms of symptom status alone. Investigators have begun to look at aspects of function and, less frequently, at quality of life, he said.

Dr. Zimmerman hopes to study whether a broader-based measure of remission, such as the RDQ, better predicts which patients are likely to relapse, compared with conventional remission measures. Another study could look at whether the RDQ is a superior outcome measure when treatment de-emphasizes symptomatic improvement, and instead focuses on functional improvement and quality of life, he said.

Dr. Zimmerman’s research was funded by Eli Lilly. He also reported financial associations with Bristol-Myers Squibb.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – A new type of scale for determining remission from depression performed well, compared with conventional measures in a study of 153 outpatients being treated for depression.

At baseline and after 3-4 months of treatment, patients completed the experimental Remission From Depression Questionnaire (RDQ) and the commonly used Quick Inventory of Depressive Symptomatology (QIDS). They were assessed using the 17-item Hamilton Depression Rating Scale (HAM-D). The QIDS and HAM-D focus on symptomatology, while the 41-item RDQ is a broader measure that includes other factors that patients have identified in previous studies as being important elements of remission, Dr. Mark Zimmerman said at the annual meeting of the American Psychiatric Association.

The effect size for all three scales were the same, meaning that the three tools were equally sensitive to change in depression, reported Dr. Zimmerman of Brown University, Providence, R.I.

Each of the seven subscales of the RDQ were sensitive to change, including subscales for symptoms of depression, other symptoms (such as anxiety or irritability), coping ability, positive mental health, functioning, life satisfaction, and general sense of well-being.

The RDQ scores were associated with self-perceived remission even after controlling for QIDS scores. In contrast, QIDS scores were associated with self-perceived remission, but not after controlling for the RDQ scores. "The RDQ is picking up variance in whether or not patients believe they are in remission above and beyond that accounted for by symptoms alone," said Dr. Zimmerman, also director of outpatient psychiatry at Rhode Island Hospital, Providence.

Historically, studies have found wide variability in the definition of remission from depression and in the terms used to describe it. A 1991 consensus conference defined remission as a score of 7 or less on the 17-item HAM-D. One of the limits of this and other definitions of remission is that they are completely symptom based with no consideration of other factors that might be important in determining how patients are doing during treatment, he said.

Dr. Zimmerman and his associates have been studying a broader concept of depression remission in studies over the past decade. "Just what this field needs – another measure to assess depression, because there aren’t enough of them already," he said sarcastically.

They initially surveyed 535 depressed outpatients to find out what they consider to be important aspects in determining remission. Among the 16 items they rated, symptom resolution didn’t make the top 4. The top factors rated by patients as important were the presence of positive mental health (selected by 77% of participants), feeling like one’s usual, normal self (76%); return to one’s usual level of functioning (74%); and feeling in emotional control (72%). When asked to choose the most important factor determining remission, 17% chose the presence of positive mental health, 14% chose feeling like one’s usual self, 11% picked a general sense of well-being, and only 10% pointed to the absence of symptoms of depression (Am. J. Psychiatry 2006;163:148-50).

"There seems to be a disconnect between what researchers have been doing all these years, which is defining remission purely in symptom terms, and what patients say are the most important considerations that they have in determining whether or not they’re in remission," he said.

Dr. Zimmerman and his associates next surveyed 514 outpatients being treated for major depressive disorder. They found that patients’ ratings of the severity of their depression, how much their symptoms have interfered with their lives or caused them difficulties, and their overall quality of life were significantly and independently associated with their view of whether or not they were in remission. (J. Psychiatr. Res. 2008;42:797-801).

The findings of these first two studies and subsequent focus groups led the investigators to develop the RDQ. In a study of 102 depressed outpatients, patients felt the RDQ was more accurate than was the symptom-based QIDS in assessing their goals and progress in treatment, and they preferred the RDQ, Dr. Zimmerman said (Ann. Clin. Psych. 2011;23:208-12).

He and his associates tested the RDQ’s reliability and validity in a study of 274 depressed outpatients in ongoing treatment, 60 of whom completed the RDQ twice to assess reliability. Patients filled out the RDQ and the QIDS, and were rated on the 17-item HAM-D and other measures. The RDQ proved to be reliable, with good internal consistency. Approximately 50% of patients were in self-reported remission according to the various measures. After researchers controlled for depression symptom severity, the RDQ identified patients who considered themselves to be in remission for reasons above and beyond symptoms status (J. Psychiatr. Res. 2013;47:78-82).

"It was capturing something unique" that the symptom-based QIDS and HAM-D scores missed, Dr. Zimmerman said. "Depressed patients’ perspective of remission goes beyond symptom resolution."

He is hopeful that the concept of remission is evolving, because outcomes in treatment trials increasingly are not being measured just in terms of symptom status alone. Investigators have begun to look at aspects of function and, less frequently, at quality of life, he said.

Dr. Zimmerman hopes to study whether a broader-based measure of remission, such as the RDQ, better predicts which patients are likely to relapse, compared with conventional remission measures. Another study could look at whether the RDQ is a superior outcome measure when treatment de-emphasizes symptomatic improvement, and instead focuses on functional improvement and quality of life, he said.

Dr. Zimmerman’s research was funded by Eli Lilly. He also reported financial associations with Bristol-Myers Squibb.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Thirty-seven percent of 175 hospitalized adolescents diagnosed with bipolar disorder met criteria for a new disorder listed in the DSM-5 – disruptive mood dysregulation disorder.

Nearly all of the patients (96%) had been diagnosed with bipolar I disorder "not otherwise specified" (NOS) at the time of admission, a retrospective study found. Three other bipolar diagnoses were applied to two patients each: bipolar depression, bipolar mania, or mixed-episode bipolar disorder, David L. Pogge, Ph.D., reported at the annual meeting of the American Psychiatric Association.

The findings suggest that a substantial proportion of adolescent inpatients diagnosed with bipolar disorder may instead meet criteria for disruptive mood dysregulation disorder, and that clinicians should be more careful in diagnosing bipolar disorder, especially bipolar NOS, said Dr. Pogge of the department of psychology and counseling at Fairleigh Dickinson University, Teaneck, N.J. He also serves as director of psychology at Four Winds Hospital, which operates four campuses in New York state.

The study included records for all 1,505 patients aged 13-17 years who were admitted to a private psychiatric hospital over a 2-year period. At the time of admission, clinicians rated 1,351 patients as having at least moderate depression and 368 as also having severe symptoms of hostility and explosiveness. They diagnosed bipolar disorder in 259 cases. The investigators analyzed records for 174 patients with complete records or who had at least moderate depression and severe symptoms of hostility and explosiveness but no signs of elation or euphoria at the time of admission.

Disruptive mood dysregulation disorder is marked by intense temper outbursts superimposed on a background of persistent depressed or irritable mood. Temper outbursts and aggression are common reasons for inpatient admissions of children and adolescents, Dr. Pogge noted in his poster presentation.

Compared with the 63% of patients who did not meet criteria for disruptive mood dysregulation disorder (DMDD), patients who met the DMDD criteria were significantly more likely to experience restraint or seclusion while hospitalized (30% vs. 20%), receive a significantly higher number of restraints or seclusions (2.2 vs. 0.8), and remain hospitalized significantly longer (25 days vs. 21 days), he reported. At the time of discharge, clinicians’ ratings on the Global Assessment of Functioning (GAF) scale indicated significantly greater global psychopathology in patients with DMDD (a mean GAF score of 44), compared with patients who did not meet DMDD criteria (a mean GAF score of 50).

The two groups did not differ significantly by age, clinician ratings of depression severity, or clinical ratings of global psychopathology at admission.

The study identified a subgroup of adolescent inpatients diagnosed with bipolar disorder without euphoric symptoms who exhibited explosiveness, hostility, and concurrent depression, comprising roughly a third of bipolar disorder diagnoses in the cohort. The findings suggest that these patients who lack signs of elevated mood and meet DMDD criteria routinely get diagnosed with bipolar I disorder, have a more problematic hospital stay, and have more symptoms at discharge, Dr. Pogge and his coinvestigators concluded.

The bipolar diagnoses might be incorrect, or there might be a substantial rate of comorbidity between DMDD and bipolar disease, he said.

The results also suggest that DMDD might be a common reason for psychiatric hospitalization of adolescents.

The study excluded patients whose records suggested other confounding factors or were missing any data on outcome measures.

Dr. Pogge reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Thirty-seven percent of 175 hospitalized adolescents diagnosed with bipolar disorder met criteria for a new disorder listed in the DSM-5 – disruptive mood dysregulation disorder.

Nearly all of the patients (96%) had been diagnosed with bipolar I disorder "not otherwise specified" (NOS) at the time of admission, a retrospective study found. Three other bipolar diagnoses were applied to two patients each: bipolar depression, bipolar mania, or mixed-episode bipolar disorder, David L. Pogge, Ph.D., reported at the annual meeting of the American Psychiatric Association.

The findings suggest that a substantial proportion of adolescent inpatients diagnosed with bipolar disorder may instead meet criteria for disruptive mood dysregulation disorder, and that clinicians should be more careful in diagnosing bipolar disorder, especially bipolar NOS, said Dr. Pogge of the department of psychology and counseling at Fairleigh Dickinson University, Teaneck, N.J. He also serves as director of psychology at Four Winds Hospital, which operates four campuses in New York state.

The study included records for all 1,505 patients aged 13-17 years who were admitted to a private psychiatric hospital over a 2-year period. At the time of admission, clinicians rated 1,351 patients as having at least moderate depression and 368 as also having severe symptoms of hostility and explosiveness. They diagnosed bipolar disorder in 259 cases. The investigators analyzed records for 174 patients with complete records or who had at least moderate depression and severe symptoms of hostility and explosiveness but no signs of elation or euphoria at the time of admission.

Disruptive mood dysregulation disorder is marked by intense temper outbursts superimposed on a background of persistent depressed or irritable mood. Temper outbursts and aggression are common reasons for inpatient admissions of children and adolescents, Dr. Pogge noted in his poster presentation.

Compared with the 63% of patients who did not meet criteria for disruptive mood dysregulation disorder (DMDD), patients who met the DMDD criteria were significantly more likely to experience restraint or seclusion while hospitalized (30% vs. 20%), receive a significantly higher number of restraints or seclusions (2.2 vs. 0.8), and remain hospitalized significantly longer (25 days vs. 21 days), he reported. At the time of discharge, clinicians’ ratings on the Global Assessment of Functioning (GAF) scale indicated significantly greater global psychopathology in patients with DMDD (a mean GAF score of 44), compared with patients who did not meet DMDD criteria (a mean GAF score of 50).

The two groups did not differ significantly by age, clinician ratings of depression severity, or clinical ratings of global psychopathology at admission.

The study identified a subgroup of adolescent inpatients diagnosed with bipolar disorder without euphoric symptoms who exhibited explosiveness, hostility, and concurrent depression, comprising roughly a third of bipolar disorder diagnoses in the cohort. The findings suggest that these patients who lack signs of elevated mood and meet DMDD criteria routinely get diagnosed with bipolar I disorder, have a more problematic hospital stay, and have more symptoms at discharge, Dr. Pogge and his coinvestigators concluded.

The bipolar diagnoses might be incorrect, or there might be a substantial rate of comorbidity between DMDD and bipolar disease, he said.

The results also suggest that DMDD might be a common reason for psychiatric hospitalization of adolescents.

The study excluded patients whose records suggested other confounding factors or were missing any data on outcome measures.

Dr. Pogge reported having no relevant financial disclosures.

sboschert@frontlinemedcom.com

On Twitter @sherryboschert

SAN FRANCISCO – Thirty-seven percent of 175 hospitalized adolescents diagnosed with bipolar disorder met criteria for a new disorder listed in the DSM-5 – disruptive mood dysregulation disorder.

Nearly all of the patients (96%) had been diagnosed with bipolar I disorder "not otherwise specified" (NOS) at the time of admission, a retrospective study found. Three other bipolar diagnoses were applied to two patients each: bipolar depression, bipolar mania, or mixed-episode bipolar disorder, David L. Pogge, Ph.D., reported at the annual meeting of the American Psychiatric Association.

The findings suggest that a substantial proportion of adolescent inpatients diagnosed with bipolar disorder may instead meet criteria for disruptive mood dysregulation disorder, and that clinicians should be more careful in diagnosing bipolar disorder, especially bipolar NOS, said Dr. Pogge of the department of psychology and counseling at Fairleigh Dickinson University, Teaneck, N.J. He also serves as director of psychology at Four Winds Hospital, which operates four campuses in New York state.

The study included records for all 1,505 patients aged 13-17 years who were admitted to a private psychiatric hospital over a 2-year period. At the time of admission, clinicians rated 1,351 patients as having at least moderate depression and 368 as also having severe symptoms of hostility and explosiveness. They diagnosed bipolar disorder in 259 cases. The investigators analyzed records for 174 patients with complete records or who had at least moderate depression and severe symptoms of hostility and explosiveness but no signs of elation or euphoria at the time of admission.

Disruptive mood dysregulation disorder is marked by intense temper outbursts superimposed on a background of persistent depressed or irritable mood. Temper outbursts and aggression are common reasons for inpatient admissions of children and adolescents, Dr. Pogge noted in his poster presentation.

Compared with the 63% of patients who did not meet criteria for disruptive mood dysregulation disorder (DMDD), patients who met the DMDD criteria were significantly more likely to experience restraint or seclusion while hospitalized (30% vs. 20%), receive a significantly higher number of restraints or seclusions (2.2 vs. 0.8), and remain hospitalized significantly longer (25 days vs. 21 days), he reported. At the time of discharge, clinicians’ ratings on the Global Assessment of Functioning (GAF) scale indicated significantly greater global psychopathology in patients with DMDD (a mean GAF score of 44), compared with patients who did not meet DMDD criteria (a mean GAF score of 50).

The two groups did not differ significantly by age, clinician ratings of depression severity, or clinical ratings of global psychopathology at admission.

The study identified a subgroup of adolescent inpatients diagnosed with bipolar disorder without euphoric symptoms who exhibited explosiveness, hostility, and concurrent depression, comprising roughly a third of bipolar disorder diagnoses in the cohort. The findings suggest that these patients who lack signs of elevated mood and meet DMDD criteria routinely get diagnosed with bipolar I disorder, have a more problematic hospital stay, and have more symptoms at discharge, Dr. Pogge and his coinvestigators concluded.

The bipolar diagnoses might be incorrect, or there might be a substantial rate of comorbidity between DMDD and bipolar disease, he said.

The results also suggest that DMDD might be a common reason for psychiatric hospitalization of adolescents.

The study excluded patients whose records suggested other confounding factors or were missing any data on outcome measures.

Dr. Pogge reported having no relevant 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 – 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 – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."

SAN FRANCISCO – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."

SAN FRANCISCO – Psychiatrists are likely to assume greater responsibility in managing cardiovascular disease risk factors among their patients with serious mental illness, according to Dr. Lydia A. Chwastiak, associate professor at the University of Washington in Seattle.

People with serious mental illness die an average of 8 years younger than the rest of the population, with most of these premature deaths tied to cardiovascular disease, she noted at the annual meeting of the American Psychiatric Association.

"We have to really think, as psychiatrists treating patients with high cardiovascular risk, should we be doing more and, if so, what should we be doing," she said. "There is an emerging group of psychiatrists and other physicians working in integrated care who have argued for an expanded role of prescribing for psychiatrists in managing disorders such as dyslipidemia."

When it comes to smoking in patients with schizophrenia, clinical practice guidelines recommend bupropion with or without nicotine replacement therapy to promote cessation.

A recent Cochrane review established that compared with placebo, bupropion increased the likelihood of cessation by threefold. The review found that varenicline increased the likelihood nearly fivefold in this population (Cochrane Database Syst. Rev. 2013;2:CD007253).

Neither drug elevated the rate of depression or positive or negative symptoms of schizophrenia, and bupropion did not elevate the rate of suicide. But varenicline possibly led to an increase in suicide intent, "so that is sort of a qualified recommendation that more research is needed and fortunately, there are ongoing trials," Dr. Chwastiak said.

Importantly, about one-third of the trials included in the review looked at smoking reduction as opposed to cessation. "What seems to be emerging is this more of a harm-reduction model, [a view] that heavier smoking confers more risk, and there is also emerging evidence that people who are able to reduce eventually are more likely to quit. So there is support for interventions that even reduce the amount of smoking," she said.

Overall, research has suggested nicotine replacement therapy alone might prove effective. Research also supports a contingency reinforcement approach, in which patients are paid to quit and abstain thereafter.

When it comes to managing dyslipidemia, reassuringly, patients with serious mental illness have a beneficial lipid response to statins similar to that of patients in the general population (Ann. Clin. Psychiatry 2013;25:141-8).

"Given that the statins appear to be as effective among people with schizophrenia, we need to think about the issues around prescribing statins," Dr. Chwastiak advised. Specifically, physicians must sort through the cytochrome P450 interactions of the various agents and choose ones that are less likely to interact with psychiatric medications.

"When we think about pharmacologic interventions [to manage cardiovascular risk factors], probably the best evidence we have really is for switching the antipsychotic medications that we are prescribing," she said.

As shown in the Comparison of Antipsychotics for Metabolic Problems trial among patients with schizophrenia or schizoaffective disorder who had adverse metabolic profiles from their medications, switching from the existing medication – olanzapine, quetiapine, or risperidone – to aripiprazole improved lipid profiles and promoted weight loss at 24 weeks (Am. J. Psychiatry 2011;168:947-56).

Importantly, switching did not increase the risk of psychiatric decompensation; however, the patients in the trial had rigorous clinical follow-up, and some did stop their treatment.

"The take-home message is that these were patients who were very closely monitored, so when medications are switched, there is a need to really monitor people both in terms of psychiatric symptoms as well as metabolic parameters," said Dr. Chwastiak, who disclosed no conflicts of interest related to her presentation.

Unfortunately, studies thus far have not found switching to improve glycemic control, although the resultant modest weight loss seen after switching can improve that outcome (as well as blood pressure control).

The only agent proven effective here is metformin, which attenuated the rise in hemoglobin A_1c levels among patients taking clozapine long term (Schizophr. Res. 2009;113:19-26).

"There is a lot of work to be done on how to manage glycemic control," Dr. Chwastiak said. "And really, there are no interventions with demonstrated effectiveness targeting diabetes or hypertension in people with serious mental illness."

A recent systematic review found that adding aripiprazole to clozapine improved total cholesterol levels, and adding topiramate to olanzapine resulted in a smaller increase in low-density lipoprotein cholesterol levels in patients with serious mental illness (AHRQ publication 12-EHC063-EF, April 2013).

"One of the interesting conclusions from this systematic review was that behavioral interventions – the lifestyle modifications – don’t seem to be any better than usual care in reducing low-density lipoprotein," Dr. Chwastiak said.

But the relevant studies were small and likely underpowered. "I don’t want that to be discouraging, suggesting that we shouldn’t be thinking about lifestyle modifications," she said. "There’s definitely improvements in cardiovascular fitness and weight reduction that really confer a benefit in terms of cardiovascular mortality."

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 – Patients with serious mental illness who are overweight or obese can lose weight and keep it off with a multifaceted behavioral intervention, a randomized trial showed.

This was one of the conclusions reached by Dr. Gail L. Daumit, lead investigator of ACHIEVE (Randomized Trial of Achieving Healthy Lifestyles in Psych Rehabilitation).

In the trial, Dr. Daumit and her associates tested a physical activity and diet modification intervention among nearly 300 overweight or obese adults attending psychiatric rehabilitation programs. After 18 months, the trial’s intervention group had lost an average of 3.2 kg more than the control group. Moreover, the intervention group continued to lose weight throughout the study period.

"Despite many challenges, with a tailored lifestyle intervention, overweight and obese adults with a serious mental illness can make lifestyle changes and achieve substantial weight loss," Dr. Daumit said while presenting the data at the annual meeting of the American Psychiatric Association. "Our findings really support implementation of a targeted behavioral weight-loss intervention in this high-risk population."

Results of the study were published recently in the New England Journal of Medicine (2013;368:1594-1602).

Dr. Daumit, associate professor of medicine at Johns Hopkins University, Baltimore, said that her findings both resembled and differed from those seen in the PREMIER trial, which tested a behavioral intervention among otherwise healthy individuals with prehypertension or mild hypertension (Ann. Intern. Med. 2006;144:485-95).

In that trial, the intervention group had a similar 2.7-kg greater weight loss than the control group. The PREMIER intervention group, however, had dramatic early weight loss followed by weight gain, whereas the ACHIEVE intervention group continued to lose weight at a more moderate pace throughout the trial.

Dr. Daumit speculated that the trials’ differing trajectories of weight loss might have resulted from the ACHIEVE patients taking more time to engage in their intervention.

"We recruited really all comers, so that in order to get into this trial, you didn’t have to be anywhere on the readiness-for-change spectrum. ... So it may have taken them then more time to make the behavioral changes. But once they made the changes, they were able to keep them," she said. "And maybe there is some limited choice in this population.

"Maybe there were some cognitive issues where they just kind of made the decision and they then just went down that path. They may have less disposable income, [and] less choice about alternatives."

As analyses were conducted according to intention to treat, patients were included even if they never attended a single session, Dr. Daumit pointed out.

"Not everyone came to sessions. So I guess the question is, ‘What’s the dose that’s needed to achieve [weight loss]?’ We are doing some kind of on-treatment analyses now where we are trying to see how much attendance was related to how much weight loss," she said.

One person who attended the session asked what kind of feedback the investigators had received from the trial participants.

"We are still in the process of trying to talk to them about that," Dr. Daumit said. "I think they definitely really liked the exercise ... and that trying to involve more social supports, they believe, would have been more helpful."

Another person in attendance asked how much cardiovascular risk reduction Dr. Daumit thinks was achieved with the weight loss.

"Our study was not powered for this," Dr. Daumit said. However, there were nonsignificant trends whereby the intervention group had roughly 5 mg/dL reductions in total and low-density lipoprotein cholesterol and glucose levels, and a 2-cm reduction in waist circumference, compared with those in the control group.

"Many participants were already taking statins and blood pressure medications and diabetes medications – this wasn’t like just a virgin untreated population," Dr. Daumit said. "So it was difficult to sort out" the intervention effect.

Dr. Daumit also expressed concern about failure of policymakers to include people with serious mental illness in their thinking, particularly in light of this population’s prevalence of overweight and obesity.

"Historically, interventions for cardiovascular disease risk reduction, including weight loss trials with tens of millions of dollars of funding by the [National Institutes of Health] for the overall population, have systematically excluded almost all mental health consumers," she noted. "All of the large trials that really kind of define our nutrition policy or other health behavior intervention policies in the U.S. exclude this population."

The 291 patients in the ACHIEVE trial were recruited from 10 Maryland psychiatric rehabilitation programs that offered meals and encouraged attendance at least twice a week. Those with an active alcohol or substance abuse disorder were excluded.

The patients were randomized evenly to a control group or a group given the 18-month intervention.

The intervention had four components: alternating group and individual weight management sessions offered at least monthly, on-site group physical activity three times weekly, and weigh-ins.

It featured simplified behavioral recommendations (such as avoiding sugary drinks, consuming five fruits and vegetables daily), physical activity goals (on-site exercise three times a week plus exercise on other days for 30 minutes on one’s own), and tracking of eating and physical activity. All program sites were given recommendations for making their menus healthier.

"We did a lot of adapting of the material to the cognitive level of the population so that people who were cognitively impaired or having a lot of mental health symptoms were able to learn in the best way," Dr. Daumit said.

On average, the study patients were 45 years old and had a body mass index of 36 kg/m². The leading mental illnesses were schizophrenia or schizoaffective disorder (seen in 58%) and bipolar disorder (22%).

The patients were taking, on average, three psychotropic medications. Fully 79% were unable to work, and 55% lived in a residential program or with a care provider.

Trial results showed that intervention patients had significantly greater weight loss when compared with their control counterparts (3.4 vs. 0.2 kg, P = .002). The intervention group was more likely to weigh the same as or less than their weight at baseline (64% vs. 49%, P less than .05) and to lose at least 5% of their body weight (38% vs. 23%, P less than .01), she said.

The study was funded by the National Institute of Mental Health. Dr. Daumit disclosed no conflicts of interest related to the research.

SAN FRANCISCO – Patients with serious mental illness who are overweight or obese can lose weight and keep it off with a multifaceted behavioral intervention, a randomized trial showed.

This was one of the conclusions reached by Dr. Gail L. Daumit, lead investigator of ACHIEVE (Randomized Trial of Achieving Healthy Lifestyles in Psych Rehabilitation).

In the trial, Dr. Daumit and her associates tested a physical activity and diet modification intervention among nearly 300 overweight or obese adults attending psychiatric rehabilitation programs. After 18 months, the trial’s intervention group had lost an average of 3.2 kg more than the control group. Moreover, the intervention group continued to lose weight throughout the study period.

"Despite many challenges, with a tailored lifestyle intervention, overweight and obese adults with a serious mental illness can make lifestyle changes and achieve substantial weight loss," Dr. Daumit said while presenting the data at the annual meeting of the American Psychiatric Association. "Our findings really support implementation of a targeted behavioral weight-loss intervention in this high-risk population."

Results of the study were published recently in the New England Journal of Medicine (2013;368:1594-1602).

Dr. Daumit, associate professor of medicine at Johns Hopkins University, Baltimore, said that her findings both resembled and differed from those seen in the PREMIER trial, which tested a behavioral intervention among otherwise healthy individuals with prehypertension or mild hypertension (Ann. Intern. Med. 2006;144:485-95).

In that trial, the intervention group had a similar 2.7-kg greater weight loss than the control group. The PREMIER intervention group, however, had dramatic early weight loss followed by weight gain, whereas the ACHIEVE intervention group continued to lose weight at a more moderate pace throughout the trial.

Dr. Daumit speculated that the trials’ differing trajectories of weight loss might have resulted from the ACHIEVE patients taking more time to engage in their intervention.

"We recruited really all comers, so that in order to get into this trial, you didn’t have to be anywhere on the readiness-for-change spectrum. ... So it may have taken them then more time to make the behavioral changes. But once they made the changes, they were able to keep them," she said. "And maybe there is some limited choice in this population.

"Maybe there were some cognitive issues where they just kind of made the decision and they then just went down that path. They may have less disposable income, [and] less choice about alternatives."

As analyses were conducted according to intention to treat, patients were included even if they never attended a single session, Dr. Daumit pointed out.

"Not everyone came to sessions. So I guess the question is, ‘What’s the dose that’s needed to achieve [weight loss]?’ We are doing some kind of on-treatment analyses now where we are trying to see how much attendance was related to how much weight loss," she said.

One person who attended the session asked what kind of feedback the investigators had received from the trial participants.

"We are still in the process of trying to talk to them about that," Dr. Daumit said. "I think they definitely really liked the exercise ... and that trying to involve more social supports, they believe, would have been more helpful."

Another person in attendance asked how much cardiovascular risk reduction Dr. Daumit thinks was achieved with the weight loss.

"Our study was not powered for this," Dr. Daumit said. However, there were nonsignificant trends whereby the intervention group had roughly 5 mg/dL reductions in total and low-density lipoprotein cholesterol and glucose levels, and a 2-cm reduction in waist circumference, compared with those in the control group.

"Many participants were already taking statins and blood pressure medications and diabetes medications – this wasn’t like just a virgin untreated population," Dr. Daumit said. "So it was difficult to sort out" the intervention effect.

Dr. Daumit also expressed concern about failure of policymakers to include people with serious mental illness in their thinking, particularly in light of this population’s prevalence of overweight and obesity.

"Historically, interventions for cardiovascular disease risk reduction, including weight loss trials with tens of millions of dollars of funding by the [National Institutes of Health] for the overall population, have systematically excluded almost all mental health consumers," she noted. "All of the large trials that really kind of define our nutrition policy or other health behavior intervention policies in the U.S. exclude this population."

The 291 patients in the ACHIEVE trial were recruited from 10 Maryland psychiatric rehabilitation programs that offered meals and encouraged attendance at least twice a week. Those with an active alcohol or substance abuse disorder were excluded.

The patients were randomized evenly to a control group or a group given the 18-month intervention.

The intervention had four components: alternating group and individual weight management sessions offered at least monthly, on-site group physical activity three times weekly, and weigh-ins.

It featured simplified behavioral recommendations (such as avoiding sugary drinks, consuming five fruits and vegetables daily), physical activity goals (on-site exercise three times a week plus exercise on other days for 30 minutes on one’s own), and tracking of eating and physical activity. All program sites were given recommendations for making their menus healthier.

"We did a lot of adapting of the material to the cognitive level of the population so that people who were cognitively impaired or having a lot of mental health symptoms were able to learn in the best way," Dr. Daumit said.

On average, the study patients were 45 years old and had a body mass index of 36 kg/m². The leading mental illnesses were schizophrenia or schizoaffective disorder (seen in 58%) and bipolar disorder (22%).

The patients were taking, on average, three psychotropic medications. Fully 79% were unable to work, and 55% lived in a residential program or with a care provider.

Trial results showed that intervention patients had significantly greater weight loss when compared with their control counterparts (3.4 vs. 0.2 kg, P = .002). The intervention group was more likely to weigh the same as or less than their weight at baseline (64% vs. 49%, P less than .05) and to lose at least 5% of their body weight (38% vs. 23%, P less than .01), she said.

The study was funded by the National Institute of Mental Health. Dr. Daumit disclosed no conflicts of interest related to the research.

SAN FRANCISCO – Patients with serious mental illness who are overweight or obese can lose weight and keep it off with a multifaceted behavioral intervention, a randomized trial showed.

This was one of the conclusions reached by Dr. Gail L. Daumit, lead investigator of ACHIEVE (Randomized Trial of Achieving Healthy Lifestyles in Psych Rehabilitation).

In the trial, Dr. Daumit and her associates tested a physical activity and diet modification intervention among nearly 300 overweight or obese adults attending psychiatric rehabilitation programs. After 18 months, the trial’s intervention group had lost an average of 3.2 kg more than the control group. Moreover, the intervention group continued to lose weight throughout the study period.

"Despite many challenges, with a tailored lifestyle intervention, overweight and obese adults with a serious mental illness can make lifestyle changes and achieve substantial weight loss," Dr. Daumit said while presenting the data at the annual meeting of the American Psychiatric Association. "Our findings really support implementation of a targeted behavioral weight-loss intervention in this high-risk population."

Results of the study were published recently in the New England Journal of Medicine (2013;368:1594-1602).

Dr. Daumit, associate professor of medicine at Johns Hopkins University, Baltimore, said that her findings both resembled and differed from those seen in the PREMIER trial, which tested a behavioral intervention among otherwise healthy individuals with prehypertension or mild hypertension (Ann. Intern. Med. 2006;144:485-95).

In that trial, the intervention group had a similar 2.7-kg greater weight loss than the control group. The PREMIER intervention group, however, had dramatic early weight loss followed by weight gain, whereas the ACHIEVE intervention group continued to lose weight at a more moderate pace throughout the trial.

Dr. Daumit speculated that the trials’ differing trajectories of weight loss might have resulted from the ACHIEVE patients taking more time to engage in their intervention.

"We recruited really all comers, so that in order to get into this trial, you didn’t have to be anywhere on the readiness-for-change spectrum. ... So it may have taken them then more time to make the behavioral changes. But once they made the changes, they were able to keep them," she said. "And maybe there is some limited choice in this population.

"Maybe there were some cognitive issues where they just kind of made the decision and they then just went down that path. They may have less disposable income, [and] less choice about alternatives."

As analyses were conducted according to intention to treat, patients were included even if they never attended a single session, Dr. Daumit pointed out.

"Not everyone came to sessions. So I guess the question is, ‘What’s the dose that’s needed to achieve [weight loss]?’ We are doing some kind of on-treatment analyses now where we are trying to see how much attendance was related to how much weight loss," she said.

One person who attended the session asked what kind of feedback the investigators had received from the trial participants.

"We are still in the process of trying to talk to them about that," Dr. Daumit said. "I think they definitely really liked the exercise ... and that trying to involve more social supports, they believe, would have been more helpful."

Another person in attendance asked how much cardiovascular risk reduction Dr. Daumit thinks was achieved with the weight loss.

"Our study was not powered for this," Dr. Daumit said. However, there were nonsignificant trends whereby the intervention group had roughly 5 mg/dL reductions in total and low-density lipoprotein cholesterol and glucose levels, and a 2-cm reduction in waist circumference, compared with those in the control group.

"Many participants were already taking statins and blood pressure medications and diabetes medications – this wasn’t like just a virgin untreated population," Dr. Daumit said. "So it was difficult to sort out" the intervention effect.

Dr. Daumit also expressed concern about failure of policymakers to include people with serious mental illness in their thinking, particularly in light of this population’s prevalence of overweight and obesity.

"Historically, interventions for cardiovascular disease risk reduction, including weight loss trials with tens of millions of dollars of funding by the [National Institutes of Health] for the overall population, have systematically excluded almost all mental health consumers," she noted. "All of the large trials that really kind of define our nutrition policy or other health behavior intervention policies in the U.S. exclude this population."

The 291 patients in the ACHIEVE trial were recruited from 10 Maryland psychiatric rehabilitation programs that offered meals and encouraged attendance at least twice a week. Those with an active alcohol or substance abuse disorder were excluded.

The patients were randomized evenly to a control group or a group given the 18-month intervention.

The intervention had four components: alternating group and individual weight management sessions offered at least monthly, on-site group physical activity three times weekly, and weigh-ins.

It featured simplified behavioral recommendations (such as avoiding sugary drinks, consuming five fruits and vegetables daily), physical activity goals (on-site exercise three times a week plus exercise on other days for 30 minutes on one’s own), and tracking of eating and physical activity. All program sites were given recommendations for making their menus healthier.

"We did a lot of adapting of the material to the cognitive level of the population so that people who were cognitively impaired or having a lot of mental health symptoms were able to learn in the best way," Dr. Daumit said.

On average, the study patients were 45 years old and had a body mass index of 36 kg/m². The leading mental illnesses were schizophrenia or schizoaffective disorder (seen in 58%) and bipolar disorder (22%).

The patients were taking, on average, three psychotropic medications. Fully 79% were unable to work, and 55% lived in a residential program or with a care provider.

Trial results showed that intervention patients had significantly greater weight loss when compared with their control counterparts (3.4 vs. 0.2 kg, P = .002). The intervention group was more likely to weigh the same as or less than their weight at baseline (64% vs. 49%, P less than .05) and to lose at least 5% of their body weight (38% vs. 23%, P less than .01), she said.

The study was funded by the National Institute of Mental Health. Dr. Daumit disclosed no conflicts of interest related to the research.

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