2015 - 2014 - 2013 - 2012 - 2011

March 5 - February 12

March 5

Below my name, some thoughts about this year’s APA election.
Once a year we include in a Sentinel Harold Eist’s reflections on the position of the County’s Chief Psychiatrist: “This position has become a roosting place for quislings, cowards, Petains, montebanks, other forms of scoundrals, and the servant of inertia.”

Tuesday, the American Medical Association and 99 other state associations asked CMS to improve their transition plans for the Oct. 1conversion to ICD-10-CM, saying that many aspects of this undertaking have not been fully assessed and that contingency plans may be inadequate. Here in the County, we hope to help both public and private clinicians be fully prepared.

March 2nd, Pediatrics suggested that physicians have been following best practice guidelines when prescribing antipsychotics to children and adolescents only about half the time, with failure to monitor cholesterol and blood sugar levels their main misstep. Of course, psychiatrists may be following the guideline more than pediatricians.

In this month’s JAACAP, three studies:
1] Despite improving working memory performance, cognitive training had limited effects on other ADHD symptoms according to assessments based on blinded measures.
2]  Olanzapine-fluoxetine combination was superior to placebo for the acute treatment of bipolar I depression in patients 10 to 17 years of age. Benefits should be weighed against the risk of adverse events, particularly weight gain and hyperlipidemia.
3] Family-base Interpersonal psychotherapy is an effective treatment for preadolescent depression.
A study found the both acamprosate and naltrexone appear to reduce the risk of individuals returning to drinking alcohol in those who are alcohol dependent. [Addiction, 02/16/2015.]
Relative to lakphy [lack of physical exercise, ICD-9-CM, V69.0; ICD-10-CM, Z72.3], two studies:
1] In people over 80 years old, neither aerobic nor resistant training produced any cognitive or mood improvements at the end of 16 weeks, suggesting 16 weeks is too short or >80 years is too old?  [Geriatr Gerontol Int, Feb, 2015.]
2] At yesterday’s American Heart Association meeting a report suggested that people who are fit in their 40s seem to retain more brain volume two decades later and also perform better on decision-making tests.

Atomoxetine is an effective treatment for the core ADHD symptoms and improves functional outcomes and quality of life, in various pediatric populations with ADHD. Initial responses to atomoxetine may be apparent within 1 week of treatment, but can take longer (median 23 days in a 6-week study). Responses often build gradually over time, and may not be robust until after 3 months. It is important that the clinician sets appropriate expectations for the patient and their family with regard to the likelihood of a gradual response, which often builds over time. [CNS Drugs, February 2015.]

For irritability in Autism, adding N-acetylcysteine 600 – 900 mg/d [from health food stores] to risperidone 1 – 2 mg/d reduced irritability and hyperactivity.  [Clinical Neuropharmacology, Jan/Feb, 2015.]
Internet-delivered cognitive behavioral therapy (iCBT) may improve access to evidence-based psychological treatment for people with these conditions. Notwithstanding the challenges of safely integrating iCBT into existing mental health services and systems, some are recommending iCBT interventions as a promising strategy for reaching and treating people with anxiety and depression who might not otherwise receive treatment.
Medication treatment of patients with borderline syndrome is common but mostly not supported by evidence from high–quality research. There is some evidence for beneficial effects by second–generation antipsychotics, mood stabilizers and omega–3 fatty acids, while the overall evidence base is still unsatisfying. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega–3 fatty acids. [Current Psychiatry Reports, 12/16/2014].   
An article in Current Opinion in Psychiatry, 12/22/2014 said:Psychotherapies are essential tools in the treatment of adult depression. Randomized trials have shown that these treatments are effective, and by focusing on key issues, such as chronic depression and relapse, psychotherapies contribute more and more to the reduction of the disease burden of depression.

Institute of medicine recommends a new name for chronic fatigues syndrome:  “Systemic exertion intolerance disease” (SEID). Diagnostic criteria are “a substantial and persistent impairment in the ability to engage in pre-illness activity levels, unrefreshing sleep, and post-exertion malaise, where the effort of even a mild activity can trigger a collapse that can last for days. Besides these three characteristics, a patient must also have cognitive impairment and/or orthostatic intolerance for an SEID diagnosis.”

Eleven days ago in the NY Times, Jeff Lieberman asked why there is an antipsychiatry movement and no anti-movement directed at any other medical specialties, such as anti-cardiology movement?  Jeff said that Psychiatry has the dubious distinction of being the only medical specialty with an anti-movement.

For those treating a patient with orthorexia, an obsession with healthy, eating and you want to code such, I would suggest ICD-9-CM, 307.9, [in the future, ICD-10-CM, F50.8.

Many articles on PTSD infer that the DSMs I [1952] did not reflect on stress as an etiological agent.  Not true.  Seventy percent of DSM-I were reactions to stress, e.g. “Schizophrenic Reaction,” not “Schizophrenia.”

The definitions of conditions in recent DSMs are different from the definitions used in the rest of medicine in being more arbitrary.  First, there is a duration-related criterion, e.g., six months for schizophrenia. Second, there is a clinician-reaction criterion that the examining clinician opines that the condition is “clinically significant.”   We have had two motions [“Action Papers”] passed by the Washington Psychiatric Society that there be an exploration of removing the arbitrariness from future DSM. Dr. Rachel Ritvo helped author the second.      


Last month the results of APA elections were announced:

President-elect Maria A. Oquendo

Secretary: Altha J. Stewart

Early Career Psychiatrist: Lama Bazzi

Under-Representative Psychiatrist: Gail Erlick Robinson

Note, all winners were women. 

There has been some disquietude over the fact that “only” twenty percent voted.  However, since there were no issues, why should anyone vote, other than those having friends running for office?  

Even if there were issues, it is not clear that an electee would be able to champion their issue.  The President-elect is supposed to represent the APA Board, not themselves.  So, an issue-based election, to be meaningful, has hurdles to clear.

This was not always true.  Harold Eist had an issue-based campaign as to APA’s attitude about managed care, and those two elections saw nearly half the Members vote.

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February 12


Time for a pop quiz:

For women over 30, which of the following is most cardiac lethal? Answer below my name.

          1] Hypertension
          2] Lakphy
          3] Obesity
          4] Smoking

New Yorker cartoon: “Most opera plots could be averted by some decent therapy.”

To prepare folks for ABPN’s written exams, we will begin attaching to Sentinels PowerPoints.  We have attached one on the topic of dementias with this Sentinel and added it to the webpage. If you find some incorrect answers, please let me know. 

Each of the twelve times I have taken the ABPN Recert exam, I have signed a statement saying I will not reveal ABPN questions.  So, my PowerPoints avoids the Board’s multiple-choice questions, questions that tests recognition.  Instead, my PowerPoints require recall, which is harder, but closer to what clinicians need to do.  Studying for recall feels like less of a waste of time than studying for recognition. 

Last year, you will recall, Congress passed a law stopping the feds, Medicare, from going ahead with their plans to switch from ICD-9-CM to ICD-10-CM last October. This year, a Congressional committee has suggested that the feds have done enough preparation for the change.  So, come October 1, the long delayed [since 1992] change may happen.  Some agencies and insurance companies may switch from ICD-IV-TR to DSM-5 at the same time. 

If there is a switch to ICD-10-CM next October, there is no reason to buy anything.  Your copy of DSM-5 has both ICD-9-CM and ICD-10-CM codes.

Should it appear that training to help facilitate the ICD change will help, we expect to be able to provide training.

This month’s AJP has a study from the Netherlands on treating psychosis and mania in the postpartum period with sequential use, first of benzodiazepine, then an antipsychotic if needed, then lithium if the first two fall short, achieving 98% remission in the acute phase and 80% sustained remission.  Psychiatry is not used to “98%” and “80%.” Did they use snake oil? While DSM-5 removes “postpartum,” for those wanting to use finding of “postpartum” in the dx, it is “648.44” in ICD-9-CM and “F53” in ICD-10-CM. [This month’s AJP also has an outstanding book review by Dr. Raymond Crowel and another on Stu Yudofsky’s FATAL PAUSES.]  

Psychotherapies are essential tools in the management of adult depression, but newer psychotherapies, such as acceptance and commitment therapy and cognitive bias modification, are not more effective than existing therapies. [Current Opinion in Psychiatry, 12/22/2014.]
A new Government Accountability Office report slams the Substance Abuse and Mental Health Services Administration (SAMHSA) for doing a lackluster job in coordinating treatment for individuals with serious mental illness.  Restated, E. Fuller Torrey has been heard again, as GAO’s reflections echoes Fuller’s testimony last year.
Electroconvulsive therapy (ECT) appears to be far more effective than algorithm-based drug therapy for treatment-resistant bipolar depression [January American Journal of Psychiatry].
While the use of Botox for the treatment of depression is off-label, the findings from recent studies are so promising that Botox’s parent company, Allergan, has begun clinical trials for its use in treating major depressive disorder in women.  Why study only women?
For severe borderline syndrome, combined therapy of fluoxetine and interpersonal psychotherapy is suggested in Psychiatry Research, 02/05/2015.
Psychiatrists who are on private insurance panels declined 17% in 2009-2010 from 2005-2006, to 55% of psychiatrists.  Medicare is also at 55%. As to Medicaid, 43%. Other medical specialties are 30% higher. [JAMA Psychiatry. 2014;71(2):176-181.]

Correct answer to pop quiz: Lakphy.

Lakphy is the most lethal of the four, especially as one ages.  Smoking is only ahead of the other three in those still in their twenties. [Tufts Health & Nutrition Letter, 5 Jan 2014].  We have all seen lots of focus on treating obesity recently with meds and so forth. One wonders if the treatment of obesity doesn’t touch a pt’s lakphy, will it be effective in reducing cardiac deaths.

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