Veterans wait too long for mental health services, reports say

Veterans diagnosed with post-traumatic stress disorder and other mental health issues often face “unconscionable” waits for treatment that leave them at risk of suicide, according to testimony at a Senate hearing Thursday and new reports from the Department of Veterans Affairs inspector general.

The reports come as VA faces unprecedented demand for mental health services from veterans returning from Iraq and Afghanistan. More than 202,000 veterans from those conflicts have been seen for potential PTSD at VA facilities through March 31, according to data released Wednesday. This is an increase of 10,000 veterans from the last quarterly report.

Retired Army Spec. Daniel Williams, who suffered a traumatic brain injury in Iraq from a makeshift bomb that also left him with PTSD, told the Senate Committee on Veterans Affairs Thursday that when he tried to reschedule an appointment to enable him to testify, he was told he would have to wait four months for a new date.

“I’m sorry not only do I have to go through this, but many of my fellow soldiers have to as well,” said Williams, who served with the 4th Infantry Division. He testified that he attempted suicide in 2004 after being unable to get psychiatric help but was saved when his gun misfired.

Williams, a resident of Homewood, Ala., described continued struggles battling red tape, waiting for appointments and trying to get attention at VA facilities. “It literally takes my wife nearly getting arrested by VA police,” he said.

“The VA system makes you want to give up and try something else,” added Williams, who testified on behalf of the National Alliance on Mental Illness….

By Steve Vogel
The Washington Post

Loughner Medication Ruling Throws Ethical Issues Into Spotlight

A federal appeals panel upheld a decision this week to deny authorities permission to forcibly medicate Jared Lee Loughner, the suspected gunman in the Tucson shooting that killed 6 people and injured 13, including US Rep. Gabrielle Giffords, with antipsychotic drugs, raising the spotlight on ethical issues surrounding the treatment of criminal defendants experiencing psychosis.

Loughner, who, according to court papers, has been diagnosed as schizophrenic, had an outburst in his first court appearance and had reportedly shown aggressive conduct, including throwing chairs in his cell, lunging at his attorney, and, on one occasion, spitting at his attorney before being declared mentally ill and unfit to stand trial by a judge on May 25.

He has since been in federal custody for hospitalization at the US Medical Center for Federal Prisoners in Springfield, Missouri.

Prior to the 9th US Court of Appeals’ issuance of a temporary stay against forcibly medicating him against his will on July 1, Loughner had been prescribed the antipsychotic drug risperidone and, if necessary, the forcible injection of the first-generation antipsychotic haloperidol (Haldol, Johnson & Johnson).

Loughner’s attorneys argued that the forced medication was intended by the court to try to make him fit to stand trial, not just representing a violation of Loughner’s constitutional rights but posing the risk for “irreparable physiological harm” and causing changes to the chemical balance in the brain that can have “serious, even fatal, side effects,” according to court documents.

“Each additional day of involuntary medication not only intensifies the brain-altering changes Mr. Loughner does not desire, but also increases the risk that Mr. Loughner will develop serious, and sometimes irreversible, physiological side effects,” the defense attorneys argued.

The drugs are standard in the treatment of schizophrenia, however, and, although not entirely free of adverse effects, they are widely considered to be safe and effective, according to psychiatrist Stephen R. Marder, MD.

“These are some of the most widely used drugs in all of medicine,” explained Dr. Marder, who is with the University of California, Los Angeles, Desert Pacific Mental Illness Research, Education, and Clinical Center in the Semel Institute for Neuroscience….

By Nancy A. Melville
Medscape Medical News

Psychiatry: Where are we going?

At the recent annual meeting of the American Psychiatric Association (APA), a talk by Dr. Laura Roberts caught my attention. In her presentation on “living up to our commitments,” Dr. Roberts, the new chair of Psychiatry at Stanford, described a dire situation for psychiatry in 2011. While some of the most disabling and deadly medical problems, neuropsychiatric illnesses, have become the leading source of medical disability in this country1, the discipline of psychiatry is often still struggling with issues of stigma, scandal, and self-doubt.

Consider these numbers. While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine. Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors (n = 698) applied for one of the 1097 post-graduate year one training positions in psychiatry2. As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent. Indeed, over the past decade the number of psychiatry training programs has fallen (from 186 to 181) and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 20113.

Beyond these numbers, the profession is struggling with its identity, a theme echoed in other plenary talks at the APA meeting. Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems4….

Tom Insel, M.D.
NIMH Director

Investing Wisely in Public Health

The biomedical philanthropist Mary Lasker once famously quipped, “If you think research is expensive, try disease.” This comment is even more relevant today, especially in thinking about the high costs of mental disorders.

Of course, this is a time of reduced funding across the federal government as Congress looks to rein in government spending. Members of both parties have stressed the need to reduce the deficit and cut spending. But this is why we must reframe the issue: is research an expense or an investment? The data argue for research as an investment — not a subsidy, entitlement, or conventional government cost.

Consider that NIH funding is an economic engine, creating $68 billion in new economic activity and nearly 500,000 jobs across 50 states in 2010. Recognizing the benefits of such an engine, other countries have begun making large new commitments to biomedical research. The Beijing Genome Institute has just purchased 128 of the new Illumina genomic sequencers, giving China a global edge for commercial sequencing. The Chinese government seems to have no doubt that the economic benefits of research accrue to those making the largest and smartest investments.

One such investment closer to home, The American Recovery and Reinvestment Act (ARRA), can now be viewed as an experiment in investing new research dollars. As part of ARRA, NIMH received $374 million for a two-year investment in 2009. Some of those funds supplemented grants that had been cut back in the preceding years. Some expanded the pool of grants with short-term awards. Some was used to boost the Institute’s autism portfolio.

But the biggest portion went into four signature projects aimed at changing our science. Two years later we can see the return on this investment in a series of new, transformative resources. The Recovery After an Initial Schizophrenia Episode (RAISE) Project, now in 35 sites, is optimizing the various approaches to early intervention following a first episode of psychosis. RAISE has the twin goals of improving clinical outcomes for patients and informing payors of what they could and should cover to avoid long-term disability….

Tom Insel, M.D.
NIMH Director

Mental Health: Think Globally, Act Locally

Accessing mental health care can be a struggle for many people around the world, in high- as well as middle- and low- income countries, and may be intertwined with a host of other, seemingly unrelated difficulties. For example, a recent story on Public Radio International reported that, for men and women with mental illness in Uganda, access to care is one part of the treatment, but securing a livelihood is an equally important next step; yet, few organizations offer assistance, and discrimination against people with mental disorders can reduce opportunities. As the ranks of unemployed and underemployed Americans continue to grow, this story is becoming more common in the U.S. as well.

These global commonalities represent an opportunity for us to learn from the experiences in other countries or among other cultures to help improve mental health care in the U.S. Using the wisdom of global shared experience, along with varied perspectives, might help psychiatry as a field to find reasonable and rational solutions to reduce the burden of mental illness. At the same time, a coordinated, global response to the major problems facing people with mental illness could speed progress toward solutions.

Today, Nature published the Grand Challenges in Global Mental Health, a synthesis of the views of more than 400 researchers, advocates, and clinicians working in more than 60 countries on mental health issues. Research specifically focused on solving these challenges could significantly transform the field and the lives of people with mental disorders. This initiative provides many reasons for excitement, but three in particular are foremost in my mind….

Tom Insel, M.D.
NIMH Director

Switching Antipsychotics May Reduce Metabolic Risks

NIMH-funded study examines whether switching to a different antipsychotic can reduce side effects while maintaining effectiveness

Patients experiencing cardiovascular or metabolic side effects while taking an antipsychotic medication may fare better if they switch to a different medication provided they are closely monitored, according to an NIMH-funded study. The study was published online ahead of print July 18, 2011, in the American Journal of Psychiatry.

Antipsychotic medications can effectively treat psychotic symptoms among people with schizophrenia or related disorders. However, the medications, especially some of those that are most commonly used, are associated with serious metabolic side effects that can lead to heart disease or diabetes. Even when patients do experience these side effects, doctors are often reluctant to change a patient’s medication regimen if the patient’s psychotic symptoms are controlled by the existing medication.

“Treating the symptoms of schizophrenia is a delicate balancing act between risks and benefits,” said National Institute of Mental Health Director Thomas R. Insel, M.D. “The possible benefits of switching medications to reduce metabolic risks must be carefully weighed against the potential risk of symptom relapse or medication failure.”

Scott Stroup, M.D., of Columbia University and colleagues aimed to determine if a medication switch could be made safely and without sacrificing clinical stability. For the Comparison of Antipsychotics for Metabolic Problems (CAMP) study, they enrolled 215 patients from 27 clinical sites whose psychotic symptoms were stabilized on one of three frequently used antipsychotics (olanzapine, quetiapine or risperidone) but were experiencing serious metabolic side effects such as weight gain and high cholesterol levels. Half of the patients were assigned to stay on their current medication, while the other half were switched to aripiprazole, another antipsychotic that is generally associated with fewer metabolic risks. All of the participants received a behavioral intervention that included a diet and exercise program designed to reduce the risk of cardiovascular disease….

Colleen Labbe
NIMH Press Office

Suicide Prevention Research Panel Symposium September 7, 2011

Ask the Experts!

As part of Suicide Prevention Awareness, NIMH is sponsoring a videocast panel of suicide prevention experts. This is a great opportunity to ask questions and hear directly from people working in the field.

When: September 7, 2011 from 2:00 to 3:30 PM EDT
Where: National Institute of Mental Health
6001 Executive Boulevard
Rockville, Maryland 20852

Those who live in the area are welcome to join us as part of the live audience. Seating is limited.

Details on the videocast and registration information will be available soon.

Don’t miss this chance to speak with the experts on suicide prevention

The Metabolic Effects of Antipsychotic Drugs

Research to be presented at the upcoming annual meeting of the Society for the Study of Ingestive Behavior (SSIB), the foremost society for research into all aspects of eating and drinking behavior, may explain why some antipsychotic drugs can promote overeating, weight gain, and insulin resistance.

Olanzapine, an atypical antipsychotic drug approved by the FDA for the treatment of schizophrenia and bipolar disorder, has been associated with body weight gain and impaired glucose homeostasis in humans and in experimental animals. As part of a Dutch research consortium, studies led by Simon Evers (University of Groningen, the Netherlands) sought to reveal underlying mechanisms for olanzapine’s metabolic effects by studying healthy adult male volunteers. The research was motivated by observations of what co-author Anton Scheurink described as “a mysterious interaction between schizophrenia and diabetes.”

Their results confirmed previous findings that olanzapine induces weight gain by increasing caloric intake, but also revealed that olanzapine reduces body temperature, which contributes to decreased energy expenditure. Indeed, reduced body temperature after olanzapine treatment may generate many of the known side effects of this antipsychotic drug. The authors’ new findings also demonstrate that olanzapine alters peripheral glucose metabolism, which may contribute to impaired insulin sensitivity.

According to lead author Simon Evers, “Our research group believes that reduced body temperature is the foremost direct and consistent effect of olanzapine in humans and in experimental animals. Reduced body temperature might explain several of olanzapine’s metabolic side effects, including increased food intake, reduced energy expenditure, sedation, high blood sugar, body weight gain, and insulin resistance.”

Reported and adapted by ScienceDaily staff
Society for the Study of Ingestive Behavior (2011, July 13). The metabolic effects of antipsychotic drugs.

New Genetic Clues for Schizophrenia; De Novo Mutations More Frequent, Study Finds

De novo mutations — genetic errors that are present in patients but not in their parents — are more frequent in schizophrenic patients than in normal individuals, according to an international group of scientists led by Dr. Guy A. Rouleau of the University of Montreal and CHU Sainte-Justine Hospital. The discovery, published in Nature Genetics, may enable researchers to define how the disease results from these mutations and eventually develop new treatments for it.

“The occurrence of de novo mutations, as observed in this study, may in part explain the high worldwide incidence of schizophrenia,” says Dr. Rouleau, who is also Director of the CHU Sainte-Justine Research Center and researcher at the University of Montreal Hospital Research Centre. “Because the mutations are located in many different genes, we can now start to establish genetic networks that would define how these gene mutations predispose to schizophrenia,” adds Simon Girard, the student who performed the key experiments that led to this discovery. “Most of the genes identified in this study have not been previously linked to schizophrenia, thereby providing new potential therapeutic targets.”

Schizophrenia is a major mental disorder characterized by a wide spectrum of symptoms, including delusions, hallucinations, disturbances in thinking, and deterioration of social behaviours. According to the World Health Organization, as many as 24 million individuals worldwide suffer from schizophrenia and over half of them are not receiving appropriate care to relieve their symptoms.

Dr. Rouleau’s team used modern DNA sequencing technologies to identify genetic changes in patients with schizophrenia whose parents showed no signs of the disease. To identify genetic mutations associated with schizophrenia, Dr. Rouleau and his team analysed approximately 20,000 genes from each participant in the study. The research team was especially interested in “de novo” mutations, meaning those that are present in patients but absent in their parents….

Reported and adapted by ScienceDaily staff

Reference: Simon L Girard, Julie Gauthier, Anne Noreau, Lan Xiong, Sirui Zhou, Loubna Jouan, Alexandre Dionne-Laporte, Dan Spiegelman, Edouard Henrion, Ousmane Diallo, Pascale Thibodeau, Isabelle Bachand, Jessie Y J Bao, Amy Hin Yan Tong, Chi-Ho Lin, Bruno Millet, Nematollah Jaafari, Ridha Joober, Patrick A Dion, Si Lok, Marie-Odile Krebs, Guy A Rouleau. Increased exonic de novo mutation rate in individuals with schizophrenia. Nature Genetics, 2011

FDA Warns of Cognitive Delay in Offspring With Valproate

The US Food and Drug Administration (FDA) has issued a safety announcement to underline the increased risk for lower cognitive test scores among children born to mothers taking the antiseizure medication valproate sodium or the related products valproic acid and divalproex sodium during pregnancy, relative to other antiepileptic medications.

Valproate products are approved to treat seizures and manic or mixed episodes associated with bipolar disorder (manic-depressive disorder), and to prevent migraine headaches, a MedWatch alert notes. They are also used off-label for other conditions, particularly other psychiatric conditions.

“FDA has evaluated all available evidence to date, and will be adding information about the risk of lower cognitive test scores to the valproate product labels in the Warnings and Precautions section, the Use in Specific Populations: Pregnancy section, and to the Medication Guides that are being developed for the valproate drug products,” the alert notes.

The FDA previously warned pregnant women and women of childbearing age about valproate use during pregnancy because of known teratogenic effects, and valproate products are assigned to Pregnancy Category D. The FDA also released an Information for Healthcare Professionals communication in December 2009 on the risk for neural tube birth defects after exposure to valproate products during pregnancy.

Their conclusion is based on epidemiologic studies showing that children exposed to valproate in utero tend to score lower on cognitive testing than children exposed to other agents….

Reported by Susan Jeffrey
Medscape Medical News