PSYCHIATRIC NEWS. Obama Calls for Major Initiative To Advance Brain Research 21 INSIDE

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1 newspaper of the american psychiatric association volume 48, number 9, May 3, 2013 PSYCHIATRIC NEWS The First and Last Word in Psychiatry ISSN Dilip Jeste, M.D., APA president, and Jeffrey Borenstein, M.D., editor in chief of Psychiatric News and president and CEO of the Brain and Behavior Research Foundation (formerly NARSAD), pose outside the White House last month after attending the meeting at which President Obama announced a $100 million proposal to study the brain in an initiative known as the Brain Research through Advancing Innovative Neurotechnologies (BRAIN). See story below. Obama Calls for Major Initiative To Advance Brain Research The Obama administration proposes a substantial investment to map the brain s connections and unlock secrets of cognition, memory, and learning. by Aaron Levin P resident Obama has proposed a $100 million project to study the workings of the human brain with the hope that discoveries may someday lead to better treatments for brain diseases. The Brain Research through Advancing Innovative Neurotechnologies (BRAIN) project will harness major government research funding providers, foundations, and the private sector to boost research intended to reveal in real time the interaction of individual brain cells and complex neural circuits. For the Obama administration, the initiative was a scientific call to arms. There is this enormous mystery waiting to be unlocked, and the BRAIN Initiative will change that by giving scientists the tools they need to get a dynamic picture of the brain in action and to better understand how we think and how we learn and how we remember, said Obama on April 2. And that knowledge could be will be transformative. Specific research allocations remain to be determined, but it appears that much of the promised resources will go first to enhance technologies like imaging systems, engineering, and bioinformatics that enable research, rather than for direct study on the brain itself. Nevertheless, many were pleased with the proposal. Pediatricians Say Same-Sex Couples Should Have Right To Marry, Adopt Saying that research documents there is no causeand-effect relationship between parents sexual orientation and children s wellbeing, pediatricians endorse same-sex marriage rights. APA took a similar position in by Ken Hausman N oting that children thrive in stable families that provide permanent security, the American Academy of Pediatrics (AAP) has become the latest medical organization to issue an official policy statement endorsing same-sex civil marriage. It also reaffirmed its position that same-gender couples, as well as single parents regardless of sexual orientation, should have the right to adopt children. A great deal of scientific research documents there is no cause-and-effect relationship between parents sexual orientation and children s well-being, the AAP statement points out. In fact, many studies attest to the normal development of children of same-gender couples when the child is wanted, the parents have a commitment to shared parenting, and the parents have strong social and economic support. The AAP statement, titled Promoting the Well-Being of Children Whose Parents Are Gay or Lesbian, emphasizes that the key factors that have a major impact on a child s norsee Brain Research on page 32 see Pediatricians on page 30 PERIODICALS: TIME SENSITIVE MATERIALS INSIDE New report describes role of psychiatrists in a rapidly changing health care system. Brain imaging shows distinct patterns in suicide attempters with depression.

2 Schizophrenia can tear patients apart For the treatment of schizophrenia LATUDA can help put your patients back together Symptom improvement was established in several pivotal trials 1 The safety and tolerability of LATUDA were evaluated in pivotal trials and multiple studies up to 52 weeks 1 The recommended starting dose, 40 mg/day, is an effective dose with no initial dose titration required. The maximum recommended dose is 160 mg/day 1 LATUDA should be taken with food (at least 350 calories) Dose adjustment is recommended in moderate and severe renal and hepatic impairment patients. The recommended starting dose is 20 mg. The dose in moderate and severe renal impairment patients and in moderate hepatic impairment patients should not exceed 80 mg/day. The dose in severe hepatic impairment patients should not exceed 40 mg/day LATUDA should not be used in combination with strong CYP3A4 inhibitors such as ketoconazole or strong CYP3A4 inducers such as rifampin. When coadministered with a moderate CYP3A4 inhibitor such as diltiazem, the recommended starting dose of LATUDA is 20 mg/day and the maximum recommended dose is 80 mg/day INDICATIONS AND USAGE LATUDA is an atypical antipsychotic indicated for the treatment of patients with schizophrenia. Efficacy was established in five 6-week controlled studies of adult patients with schizophrenia. The effectiveness of LATUDA for longer-term use, that is, for more than 6 weeks, has not been established in controlled studies. Therefore, the physician who elects to use LATUDA for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. IMPORTANT SAFETY INFORMATION FOR LATUDA WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS See full prescribing information for complete boxed warning. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. LATUDA is not approved for the treatment of patients with dementia-related psychosis. Please see additional Important Safety Information, including Boxed Warning, and Brief Summary of Prescribing Information on adjacent pages. LATUDA and are registered trademarks of Dainippon Sumitomo Pharma Co., Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Dainippon Sumitomo Pharma Co., Ltd Sunovion Pharmaceuticals Inc. All rights reserved. 9/12 LATV367-12

3 INDICATIONS AND USAGE LATUDA is an atypical antipsychotic agent indicated for the treatment of patients with schizophrenia. Efficacy was established in five 6-week controlled studies of adult patients with schizophrenia. The effectiveness of LATUDA for longer-term use, that is, for more than 6 weeks, has not been established in controlled studies. Therefore, the physician who elects to use LATUDA for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. ImpOrTANT SAfETy INfOrmATION for LATUDA WArNING: INCrEASED mortality IN ELDErLy patients WITH DEmENTIA-rELATED psychosis See full prescribing information for complete boxed warning. Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. LATUDA is not approved for the treatment of patients with dementia-related psychosis. CONTrAINDICATIONS LATUDA is contraindicated in the following: Any patient with a known hypersensitivity to lurasidone HCl or any components in the formulation. Angioedema has been observed with lurasidone. Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole). Concomitant use with strong CYP3A4 inducers (e.g., rifampin). WArNINGS AND precautions Cerebrovascular Adverse Reactions, Including Stroke: LATUDA is not approved for the treatment of patients with dementia-related psychosis. Neuroleptic Malignant Syndrome (NMS): NMS, a potentially fatal symptom complex, has been reported with administration of antipsychotic drugs, including LATUDA. NMS can cause hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure. The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; 2) intensive symptomatic treatment and medical monitoring; and 3) treatment of any concomitant serious medical problems for which specific treatments are available. Tardive Dyskinesia (TD): The risk of developing TD and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses. Given these considerations, LATUDA should be prescribed in a manner that is most likely to minimize the occurrence of TD. If signs and symptoms appear in a patient on LATUDA, drug discontinuation should be considered. Metabolic Changes Hyperglycemia and Diabetes Mellitus: Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug. Dyslipidemia: Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics. Weight Gain: Weight gain has been observed with atypical antipsychotic use. Clinical monitoring of weight is recommended. Hyperprolactinemia: As with other drugs that antagonize dopamine D2 receptors, LATUDA elevates prolactin levels. Galactorrhea, amenorrhea, gynecomastia, and impotence have been reported in patients receiving prolactin-elevating compounds. Leukopenia, Neutropenia, and Agranulocytosis: Leukopenia/ neutropenia has been reported during treatment with antipsychotic agents. Agranulocytosis (including fatal cases) has been reported with other agents in the class. Patients with a preexisting low white blood cell count (WBC) or a history of drug induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy, and LATUDA should be discontinued at the first sign of a decline in WBC in the absence of other causative factors. Orthostatic Hypotension and Syncope: LATUDA may cause orthostatic hypotension. Orthostatic vital signs should be monitored in patients who are vulnerable to hypotension and in patients with known cardiovascular disease or cerebrovascular disease. Seizures: LATUDA should be used cautiously in patients with a history of seizures or with conditions that lower seizure threshold (e.g., Alzheimer s dementia). Potential for Cognitive and Motor Impairment: In short-term, placebo-controlled trials, somnolence was reported in 17.0% (256/1508) of patients treated with LATUDA compared to 7.1% (50/708) of placebo patients, respectively. Patients should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that therapy with LATUDA does not affect them adversely. Body Temperature Regulation: Disruption of the body s ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing LATUDA for patients who will be experiencing conditions that may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration. Suicide: The possibility of suicide attempt is inherent in psychotic illness and close supervision of high-risk patients should accompany drug therapy. Prescriptions for LATUDA should be written for the smallest quantity of tablets consistent with good patient management in order to reduce the risk of overdose. Dysphagia: Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer s dementia. LATUDA and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia. ADVErSE reactions Commonly Observed Adverse Reactions: (incidence 5% and at least twice the rate of placebo) in patients treated with LATUDA were somnolence, akathisia, nausea and parkinsonism. Please see brief summary of prescribing information on adjacent pages, including Boxed Warning. Reference: 1. LATUDA prescribing information. Sunovion Pharmaceuticals Inc. May FOR MORE INFORMATION, PLEASE CALL OR VISIT

4 Brief Summary (for Full Prescribing Information, see package insert) WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Warnings and Precautions (5.1)]. LATUDA is not approved for use in patients with dementia-related psychosis [see Warnings and Precautions 5.1)]. 1 INDICATIONS AND USAGE LATUDA is indicated for the treatment of patients with schizophrenia. The efficacy of LATUDA in schizophrenia was established in five 6-week controlled studies of adult patients with schizophrenia [Clinical Studies (14.1)]. The effectiveness of LATUDA for longer-term use, that is, for more than 6 weeks, has not been established in controlled studies. Therefore, the physician who elects to use LATUDA for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient [see Dosage and Administration (2)]. 4 CONTRAINDICATIONS LATUDA is contraindicated in the following: Any patient with a known hypersensitivity to lurasidone HCl or any components in the formulation. Angioedema has been observed with lurasidone [see Adverse Reactions (6.1)]. Concomitant use with strong CYP3A4 inhibitors (e.g., ketoconazole) [see Drug Interactions (7.1)]. Concomitant use with strong CYP3A4 inducers (e.g., rifampin) [see Drug Interactions (7.1)]. 5 WARNINGS AND PRECAUTIONS 5.1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6- to 1.7- times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drugtreated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. LATUDA is not approved for the treatment of patients with dementiarelated psychosis [see Boxed Warning]. 5.2 Cerebrovascular Adverse Reactions, Including Stroke in Elderly Patients with Dementia-Related Psychosis In placebo-controlled trials with risperidone, aripiprazole, and olanzapine in elderly subjects with dementia, there was a higher incidence of cerebrovascular adverse reactions (cerebrovascular accidents and transient ischemic attacks), including fatalities, compared to placebo-treated subjects. LATUDA is not approved for the treatment of patients with dementia-related psychosis [see also Boxed Warning and Warnings and Precautions (5.1)]. 5.3 Neuroleptic Malignant Syndrome A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including LATUDA. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia). Additional signs may include elevated creatinine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure. The diagnostic evaluation of patients with this syndrome is complicated. It is important to exclude cases where the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology. The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; 2) intensive symptomatic treatment and medical monitoring; and 3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for NMS. If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. If reintroduced, the patient should be carefully monitored, since recurrences of NMS have been reported. 5.4 Tardive Dyskinesia Tardive dyskinesia is a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements that can develop in patients treated with antipsychotic drugs. Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome. Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown. The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses. There is no known treatment for established cases of tardive dyskinesia, although the syndrome may remit, partially or completely, if antipsychotic treatment is withdrawn. Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome and thereby may possibly mask the underlying process. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown. Given these considerations, LATUDA should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients who suffer from a chronic illness that (1) is known to respond to antipsychotic drugs, and (2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically. If signs and symptoms of tardive dyskinesia appear in a patient on LATUDA, drug discontinuation should be considered. However, some patients may require treatment with LATUDA despite the presence of the syndrome. 5.5 Metabolic Changes Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/cerebrovascular risk. These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain. While all of the drugs in the class have been shown to produce some metabolic changes, each drug has its own specific risk profile. Hyperglycemia and Diabetes Mellitus Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse events is not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychotics. Because LATUDA was not marketed at the time these studies were performed, it is not known if LATUDA is associated with this increased risk. Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of antidiabetic treatment despite discontinuation of the suspect drug. Pooled data from short-term, placebo-controlled studies are presented in Table 1. Table 1: Change in Fasting Glucose LATUDA Placebo 20 mg/day 40 mg/day 80 mg/day 120 mg/day 160 mg/day Mean Change from Baseline (mg/dl) n=680 n=71 n=478 n=508 n=283 n=113 Serum Glucose Proportion of Patients with Shifts to 126 mg/dl Serum Glucose ( 126 mg/dl) 8.3% (52/628) 11.7% (7/60) 12.7% (57/449) 6.8% (32/472) 10.0% (26/260) 5.6% (6/108) In the uncontrolled, longer-term studies (primarily open-label extension studies), LATUDA was associated with a mean change in glucose of +1.8 mg/dl at week 24 (n=355), +0.8 mg/dl at week 36 (n=299) and +2.3 mg/dl at week 52 (n=307). Dyslipidemia Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics. Pooled data from short-term, placebo-controlled studies are presented in Table 2. Table 2: Change in Fasting Lipids LATUDA Placebo 20 mg/day 40 mg/day 80 mg/day 120 mg/day 160 mg/day Mean Change from Baseline (mg/dl) n=660 n=71 n=466 n=499 n=268 n=115 Total cholesterol Triglycerides Proportion of Patients with Shifts Total Cholesterol ( 240 mg/dl) Triglycerides ( 200 mg/dl) 5.3% (30/571) 10.1% (53/526) 13.8% (8/58) 14.3% (7/49) 6.2% (25/402) 10.8% (41/379) 5.3% (23/434) 6.3% (25/400) 3.8% (9/238) 10.5% (22/209) 4.0% (4/101) 7.0% (7/100) In the uncontrolled, longer-term studies (primarily open-label extension studies), LATUDA was associated with a mean change in total cholesterol and triglycerides of 3.8 (n=356) and 15.1 (n=357) mg/dl at week 24, 3.1 (n=303) and 4.8 (n=303) mg/dl at week 36 and 2.5 (n=307) and 6.9 (n=307) mg/dl at week 52, respectively. Weight Gain Weight gain has been observed with atypical antipsychotic use. Clinical monitoring of weight is recommended. Pooled data from short-term, placebo-controlled studies are presented in Table 4. The mean weight gain was 0.43 kg for LATUDA-treated patients compared to 0.02 kg for placebo-treated patients. Change in weight from baseline for olanzapine was 4.15 kg and for quetiapine extended-release was 2.09 kg in Studies 3 and 5 [see Clinical Studies (14.1)], respectively. The proportion of patients with a 7% increase in body weight (at Endpoint) was 4.8% for LATUDA-treated patients versus 3.3% for placebo-treated patients. Table 3: Mean Change in Weight (kg) from Baseline LATUDA Placebo (n=696) 20 mg/day (n=71) 40 mg/day (n=484) 80 mg/day (n=526) 120 mg/day (n=291) 160 mg/day (n=114) All Patients In the uncontrolled, longer-term studies (primarily open-label extension studies), LATUDA was associated with a mean change in weight of 0.69 kg at week 24 (n=755), 0.59 kg at week 36 (n=443) and 0.73 kg at week 52 (n=377). 5.6 Hyperprolactinemia As with other drugs that antagonize dopamine D2 receptors, LATUDA elevates prolactin levels. Hyperprolactinemia may suppress hypothalamic GnRH, resulting in reduced pituitary gonadotrophin secretion. This, in turn, may inhibit reproductive function by impairing gonadal steroidogenesis in both female and male patients. Galactorrhea, amenorrhea, gynecomastia, and impotence have been reported with prolactin-elevating compounds. Long-standing hyperprolactinemia, when associated with hypogonadism, may lead to decreased bone density in both female and male patients [see Adverse Reactions (6)]. In short-term, placebo-controlled studies, the median change from baseline to endpoint in prolactin levels for LATUDA-treated patients was 0.4 ng/ml and was 1.9 ng/ml in the placebo-treated patients. The median change from baseline to endpoint for males was 0.5 ng/ml and for females was 0.2 ng/ml. Median changes for prolactin by dose are shown in Table 5. Table 4: Median Change in Prolactin (ng/ml) from Baseline LATUDA Placebo 20 mg/day 40 mg/day 80 mg/day 120 mg/day 160 mg/day All Patients 1.9 (n=672) 1.1 (n=70) 1.4 (n=476) 0.2 (n=495) 3.3 (n=284) 3.3 (n=115) Females 5.1 (n=200) 0.7 (n=19) 4.0 (n=149) 0.2 (n=150) 6.7 (n=70) 7.1 (n=36) Males 1.3 (n=472) 1.2 (n=51) 0.7 (n=327) 0.2 (n=345) 3.1 (n=214) 2.4 (n=79) The proportion of patients with prolactin elevations 5 upper limit of normal (ULN) was 2.8% for LATUDA-treated patients versus 1.0% for placebo-treated patients. The proportion of female patients with prolactin elevations 5x ULN was 5.7% for LATUDA-treated patients versus 2.0% for placebo-treated female patients. The proportion of male patients with prolactin elevations > 5x ULN was 1.6% versus 0.6% for placebo-treated male patients. In the uncontrolled longer-term studies (primarily open-label extension studies), LATUDA was associated with a median change in prolactin of 0.9 ng/ml at week 24 (n=357), 5.3 ng/ml at week 36 (n=190) and 2.2 ng/ml at week 52 (n=307). Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin-dependent in vitro, a factor of potential importance if the prescription of these drugs is considered in a patient with previously detected breast cancer. As is common with compounds which increase prolactin release, an increase in mammary gland neoplasia was observed in a LATUDA carcinogenicity study conducted in rats and mice [see Nonclinical Toxicology (13)]. Neither clinical studies nor epidemiologic studies conducted to date have shown an association between chronic administration of this class of drugs and tumorigenesis in humans, but the available evidence is too limited to be conclusive. 5.7 Leukopenia, Neutropenia and Agranulocytosis Leukopenia/neutropenia has been reported during treatment with antipsychotic agents. Agranulocytosis (including fatal cases) has been reported with other agents in the class. Possible risk factors for leukopenia/neutropenia include pre-existing low white blood cell count (WBC) and history of drug-induced leukopenia/ neutropenia. Patients with a pre-existing low WBC or a history of druginduced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy and LATUDA should be discontinued at the first sign of decline in WBC, in the absence of other causative factors. Patients with neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur. Patients with severe neutropenia (absolute neutrophil count < 1000/mm 3 ) should discontinue LATUDA and have their WBC followed until recovery. 5.8 Orthostatic Hypotension and Syncope LATUDA may cause orthostatic hypotension, perhaps due to its α1- adrenergic receptor antagonism. The incidence of orthostatic hypotension and syncope events from short-term, placebo-controlled studies was (LATUDA incidence, placebo incidence): orthostatic hypotension [0.3% (5/1508), 0.1% (1/708)] and syncope [0.1% (2/1508), 0% (0/708)]. Assessment of orthostatic hypotension was defined by vital sign changes ( 20 mm Hg decrease in systolic blood pressure and 10 bpm increase in pulse from sitting to standing or supine to standing positions). In short-term clinical trials, orthostatic hypotension occurred with a frequency of 0.8% with LATUDA 40 mg, 2.1% with LATUDA 80 mg, 1.7% with LATUDA 120 mg and 0.8% with LATUDA 160 mg compared to 0.7% with placebo. Orthostatic vital signs should be monitored in patients who are vulnerable to hypotension (e.g., dehydration, hypovolemia, and treatment with antihypertensive medications), and in patients with known cardiovascular disease (e.g., heart failure, history of myocardial infarction, ischemia, or conduction abnormalities), or cerebrovascular disease. 5.9 Seizures As with other antipsychotic drugs, LATUDA should be used cautiously in patients with a history of seizures or with conditions that lower the seizure threshold, e.g., Alzheimer s dementia. Conditions that lower the seizure threshold may be more prevalent in patients 65 years or older. In short-term, placebo-controlled trials, seizures/convulsions occurred in 0.1% (2/1508) of patients treated with LATUDA compared to 0.1% (1/708) placebo-treated patients Potential for Cognitive and Motor Impairment LATUDA, like other antipsychotics, has the potential to impair judgment, thinking or motor skills. In short-term, placebo-controlled trials, somnolence was reported by 17.0% (256/1508) of patients treated with LATUDA (15.5% LATUDA 20 mg, 15.6% LATUDA 40 mg, 15.2% LATUDA 80 mg, 26.5% LATUDA 120 mg and 8.3% LATUDA 160 mg/day) compared to 7.1% (50/708) of placebo patients. In these short-term trials, somnolence included: hypersomnia, hypersomnolence, sedation and somnolence. Patients should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that therapy with LATUDA does not affect them adversely Body Temperature Regulation Disruption of the body s ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing LATUDA for patients who will be experiencing conditions that

5 may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration [see Patient Counseling Information (17.9)] Suicide The possibility of a suicide attempt is inherent in psychotic illness and close supervision of high-risk patients should accompany drug therapy. Prescriptions for LATUDA should be written for the smallest quantity of tablets consistent with good patient management in order to reduce the risk of overdose. In short-term, placebo-controlled studies in patients with schizophrenia, the incidence of treatment-emergent suicidal ideation was 0.4% (6/1508) for LATUDA-treated patients compared to 0.8% (6/708) on placebo. No suicide attempts or completed suicides were reported in these studies Dysphagia Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in elderly patients, in particular those with advanced Alzheimer s dementia. LATUDA and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia Use in Patients with Concomitant Illness Clinical experience with LATUDA in patients with certain concomitant illnesses is limited [see Clinical Pharmacology (12.3)]. Patients with Parkinson s Disease or Dementia with Lewy Bodies are reported to have an increased sensitivity to antipsychotic medication. Manifestations of this increased sensitivity include confusion, obtundation, postural instability with frequent falls, extrapyramidal symptoms, and clinical features consistent with the neuroleptic malignant syndrome. LATUDA has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from premarketing clinical trials. Because of the risk of orthostatic hypotension with LATUDA, caution should be observed in patients with known cardiovascular disease [see Warnings and Precautions (5.8)]. 6 ADVERSE REACTIONS The following adverse reactions are discussed in more detail in other sections of the labeling: Use in Elderly Patients with Dementia-Related Psychosis [see Boxed Warning and Warnings and Precautions (5.1)] Cerebrovascular Adverse Reactions, Including Stroke [see Warnings and Precautions (5.2)] Neuroleptic Malignant Syndrome [see Warnings and Precautions (5.3)] Tardive Dyskinesia [see Warnings and Precautions (5.4)] Hyperglycemia and Diabetes Mellitus [see Warnings and Precautions (5.5)] Hyperprolactinemia [see Warnings and Precautions (5.6)] Leukopenia, Neutropenia, and Agranulocytosis [see Warnings and Precautions (5.7)] Orthostatic Hypotension and Syncope [see Warnings and Precautions (5.8)] Seizures [see Warnings and Precautions (5.9)] Potential for Cognitive and Motor Impairment [see Warnings and Precautions (5.10)] Body Temperature Regulation [see Warnings and Precautions (5.11)] Suicide [see Warnings and Precautions (5.12)] Dysphagia [see Warnings and Precautions (5.13)] 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. The information below is derived from a clinical study database for LATUDA consisting of 2905 patients with schizophrenia exposed to one or more doses with a total experience of patient-years. Of these patients, 1508 participated in short-term, placebo-controlled schizophrenia studies with doses of 20 mg, 40 mg, 80 mg, 120 mg or 160 mg once daily. A total of 769 LATUDA-treated patients had at least 24 weeks and 371 LATUDAtreated patients had at least 52 weeks of exposure. Adverse events during exposure to study treatment were obtained by general inquiry and voluntarily reported adverse experiences, as well as results from physical examinations, vital signs, ECGs, weights and laboratory investigations. Adverse experiences were recorded by clinical investigators using their own terminology. In order to provide a meaningful estimate of the proportion of individuals experiencing adverse events, events were grouped in standardized categories using MedDRA terminology. The following findings are based on the short-term, placebo-controlled premarketing studies for schizophrenia in which LATUDA was administered at daily doses ranging from 20 to 160 mg (n=1508). Commonly Observed Adverse Reactions: The most common adverse reactions (incidence 5% and at least twice the rate of placebo) in patients treated with LATUDA were somnolence, akathisia, nausea and parkinsonism. Adverse Reactions Associated with Discontinuation of Treatment: A total of 9.5% (143/1508) LATUDA-treated patients and 9.3% (66/708) of placebotreated patients discontinued due to adverse reactions. There were no adverse reactions associated with discontinuation in subjects treated with LATUDA that were at least 2% and at least twice the placebo rate. Adverse Reactions Occurring at an Incidence of 2% or More in LATUDA- Treated Patients: Adverse reactions associated with the use of LATUDA (incidence of 2% or greater, rounded to the nearest percent and LATUDA incidence greater than placebo) that occurred during acute therapy (up to 6 weeks in patients with schizophrenia) are shown in Table 5. Table 5: Adverse Reactions in 2% or More of LATUDA-Treated Patients and That Occurred at Greater Incidence than in the Placebo-Treated Patients in Short-term Schizophrenia Studies Body System or Organ Class Dictionary-derived Term Gastrointestinal Disorders Percentage of Patients Reporting Reaction Placebo (N=708) All LATUDA (N=1508) Nausea 5 10 Vomiting 6 8 Dyspepsia 5 6 Salivary Hypersecretion <1 2 Body System or Organ Class Dictionary-derived Term Percentage of Patients Reporting Reaction Placebo (N=708) Musculoskeletal and Connective Tissue Disorders All LATUDA (N=1508) Back Pain 2 3 Nervous System Disorders Somnolence* 7 17 Akathisia 3 13 Parkinsonism** 5 10 Dizziness 2 4 Dystonia*** <1 4 Psychiatric Disorders Insomnia 8 10 Agitation 4 5 Anxiety 4 5 Restlessness 1 2 Note: Figures rounded to the nearest integer * Somnolence includes adverse event terms: hypersomnia, hypersomnolence, sedation, and somnolence ** Parkinsonism includes adverse event terms: bradykinesia, cogwheel rigidity, drooling, extrapyramidal disorder, hypokinesia, muscle rigidity, parkinsonism, psychomotor retardation, and tremor *** Dystonia includes adverse event terms: dystonia, oculogyric crisis, oromandibular dystonia, tongue spasm, torticollis, and trismus Dose-Related Adverse Reactions In pooled data from the short-term, placebo-controlled, fixed-dose studies, there were no dose-related adverse reactions (greater than 5% incidence) in patients treated with LATUDA across the 20 mg/day to 160 mg/day dose range. However, the frequency of akathisia increased with dose up to 120 mg/day (5.6% LATUDA 20 mg, 10.7% LATUDA 40 mg, 12.3% LATUDA 80 mg, 22.0% LATUDA 120 mg); akathisia was reported by 7.4% (9/121) of patients receiving 160 mg/day. Akathisia occurred in 3.0% of subjects receiving placebo. Extrapyramidal Symptoms In the short-term, placebo-controlled schizophrenia studies, for LATUDAtreated patients, the incidence of reported events related to extrapyramidal symptoms (EPS), excluding akathisia and restlessness, was 13.5% versus 5.8% for placebo-treated patients. The incidence of akathisia for LATUDAtreated patients was 12.9% versus 3.0% for placebo-treated patients. Incidence of EPS by dose is provided in Table 7. Table 6: Incidence of EPS Compared to Placebo Adverse Event Term Placebo (N=709) (%) 20 mg/day (N=71) (%) 40 mg/day (N=487) (%) LATUDA 80 mg/day (N=538) (%) 120 mg/day (N=291) (%) 160 mg/day (N=121) (%) All EPS events All EPS events, excluding Akathisia/ Restlessness Akathisia Dystonia* < Parkinsonism** Restlessness Note: Figures rounded to the nearest integer * Dystonia includes adverse event terms: dystonia, oculogyric crisis, oromandibular dystonia, tongue spasm, torticollis, and trismus ** Parkinsonism includes adverse event terms: bradykinesia, cogwheel rigidity, drooling, extrapyramidal disorder, hypokinesia, muscle rigidity, parkinsonism, psychomotor retardation, and tremor In the short-term, placebo-controlled schizophrenia studies, data was objectively collected on the Simpson Angus Rating Scale for extrapyramidal symptoms (EPS), the Barnes Akathisia Scale (for akathisia) and the Abnormal Involuntary Movement Scale (for dyskinesias). The mean change from baseline for LATUDA-treated patients was comparable to placebo-treated patients, with the exception of the Barnes Akathisia Scale global score (LATUDA, 0.1; placebo, 0.0). The percentage of patients who shifted from normal to abnormal was greater in LATUDA-treated patients versus placebo for the BAS (LATUDA, 14.4%; placebo, 7.1%) and the SAS (LATUDA, 5.0%; placebo, 2.3%). Dystonia Class Effect: Symptoms of dystonia, prolonged abnormal contractions of muscle groups, may occur in susceptible individuals during the first few days of treatment. Dystonic symptoms include: spasm of the neck muscles, sometimes progressing to tightness of the throat, swallowing difficulty, difficulty breathing, and/or protrusion of the tongue. While these symptoms can occur at low doses, they occur more frequently and with greater severity with high potency and at higher doses of first-generation antipsychotic drugs. An elevated risk of acute dystonia is observed in males and younger age groups. In the short-term, placebo-controlled clinical trials, dystonia occurred in 4.2% of LATUDA-treated subjects (0.0% LATUDA 20 mg, 3.5% LATUDA 40 mg, 4.5% LATUDA 80 mg, 6.5% LATUDA 120 mg and 2.5% LATUDA 160 mg) compared to 0.8% of subjects receiving placebo. Seven subjects (0.5%, 7/1508) discontinued clinical trials due to dystonic events four were receiving LATUDA 80 mg/day and three were receiving LATUDA 120 mg/day. Other Adverse Reactions Observed During the Premarketing Evaluation of LATUDA Following is a list of adverse reactions reported by patients treated with LATUDA at multiple doses of 20 mg once daily during any phase of a study within the database of 2905 patients. The reactions listed are those that could be of clinical importance, as well as reactions that are plausibly drugrelated on pharmacologic or other grounds. Reactions listed in Table 5 or those that appear elsewhere in the LATUDA label are not included. Although the reactions reported occurred during treatment with LATUDA, they were not necessarily caused by it. Reactions are further categorized by organ class and listed in order of decreasing frequency according to the following definitions: those occurring in at least 1/100 patients (frequent) (only those not already listed in the tabulated results from placebo-controlled studies appear in this listing); those occurring in 1/100 to 1/1000 patients (infrequent); and those occurring in fewer than 1/1000 patients (rare). Blood and Lymphatic System Disorders: Infrequent: anemia Cardiac Disorders: Frequent: tachycardia; Infrequent: AV block 1st degree, angina pectoris, bradycardia Ear and Labyrinth Disorders: Infrequent: vertigo Eye Disorders: Frequent: blurred vision Gastrointestinal Disorders: Frequent: abdominal pain, diarrhea; Infrequent: gastritis General Disorders and Administrative Site Conditions: Rare: sudden death Investigations: Frequent: CPK increased Metabolism and Nutritional System Disorders: Frequent: decreased appetite Musculoskeletal and Connective Tissue Disorders: Rare: rhabdomyolysis Nervous System Disorders: Infrequent: cerebrovascular accident, dysarthria Psychiatric Disorders: Infrequent: abnormal dreams, panic attack, sleep disorder; Renal and Urinary Disorders: Infrequent: dysuria; Rare: renal failure Reproductive System and Breast Disorders: Infrequent: amenorrhea, dysmenorrhea; Rare: breast enlargement, breast pain, galactorrhea, erectile dysfunction Skin and Subcutaneous Tissue Disorders: Frequent: rash, pruritus; Rare: angioedema Vascular Disorders: Frequent: hypertension 7 DRUG INTERACTIONS 7.1 Potential for Other Drugs to Affect LATUDA LATUDA is predominantly metabolized by CYP3A4. LATUDA should not be used in combination with strong inhibitors or inducers of this enzyme [see Contraindications (4)] and dose should be limited when used in combination with moderate inhibitors of CYP3A4 [see Dosage and Administration (2.4)]. No dose adjustment is needed with concomitant use of lithium (see Figure 1). Figure 1: Impact of Other Drugs on LATUDA Pharmacokinetics Interacting drug PK Strong CYP3A4 Inhibitor Ketoconazole 400 mg/day Cmax AUC Moderate CYP3A4 Inhibitor Diltiazem Cmax 240 mg/day AUC Strong CYP3A4 Inducer Rifampin Cmax 600 mg/day Lithium 600 mg BID AUC Cmax AUC Fold Change and 90% CI Change relative to lurasidone alone Recommendation Should not be coadministered Starting dose = 20 mg Maximum dose = 80 mg Should not be coadministered Adjustment not required 7.2 Potential for LATUDA to Affect Other Drugs No adjustment is needed on the dose of lithium, or substrates of P-gp or CYP3A4 when coadministered with LATUDA (Figure 2). Figure 2: Impact of LATUDA on Other Drugs Interacting drug PK P-gp Substrates Digoxin 0.25 mg SD Cmax AUC CYP3A4 Substrates Midazolam Cmax 5 mg SD AUC Oral Contraceptive Ethinyl Cmax Estradiol AUC Fold Change and 90% CI Recommendation Adjustment not required Adjustment not required Adjustment not required Norelgestromin Cmax Adjustment not required AUC Lithium 600 mg BID* Ctrough Adjustment not required Change Relative to Interactive Drug Alone *Steady state lithium Ctrough on Day 4 vs Day 8 when lithium was coadministered with lurasidone at steady state 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Teratogenic Effects Pregnancy Category B LATUDA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Non-teratogenic Effects Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress and feeding disorder in these neonates. These complications have varied in severity; while in some cases symptoms have been self-limited, in other cases neonates have required intensive care unit support and prolonged hospitalization. Safe use of LATUDA during pregnancy or lactation has not been established; therefore, use of LATUDA in pregnancy, in nursing mothers, or in women of childbearing potential requires that the benefits of treatment be weighed against the possible risks to mother and child.

6 Animal Data No adverse developmental effects were seen in a study in which pregnant rats were given LATUDA during the period of organogenesis and continuing through weaning at doses up to 10 mg/kg/day; this dose is approximately half of the MRHD based on body surface area. No teratogenic effects were seen in studies in which pregnant rats and rabbits were given LATUDA during the period of organogenesis at doses up to 25 and 50 mg/kg/day, respectively. These doses are 1.5- and 6- times, in rats and rabbits respectively, the maximum recommended human dose (MRHD) of 160 mg/day based on body surface area. 8.3 Nursing Mothers LATUDA was excreted in milk of rats during lactation. It is not known whether LATUDA or its metabolites are excreted in human milk. Because of the potential for serious adverse reactions in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, considering risk of drug discontinuation to the mother. 8.4 Pediatric Use Safety and effectiveness in pediatric patients have not been established. 8.5 Geriatric Use Clinical studies of LATUDA in the treatment of schizophrenia did not include sufficient numbers of patients aged 65 and older to determine whether or not they respond differently from younger patients. In elderly patients with psychosis (65 to 85), LATUDA concentrations (20 mg/day) were similar to those in young subjects [see Clinical Pharmacology (12.3)]. No dose adjustment is necessary in elderly patients (Figure 2). Elderly patients with dementia-related psychosis treated with LATUDA are at an increased risk of death compared to placebo. LATUDA is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning]. 8.6 Other Patient Factors The effect of intrinsic patient factors on the pharmacokinetics of LATUDA is presented in Figure 3. Figure 3: Impact of Other Patient Factors on LATUDA Pharmacokinetics PK Renal impairment Mild Cmax AUC Moderate Cmax AUC Severe Cmax AUC Hepatic impairment Mild Cmax AUC Moderate Cmax AUC Severe Cmax AUC Population description Fold Change and 90% CI Recommendation Adjustment not required Starting dose = 20 mg Maximum dose = 80 mg Starting dose = 20 mg Maximum dose = 80 mg Adjustment not required Starting dose = 20 mg Maximum dose = 80 mg Starting dose = 20 mg Maximum dose = 40 mg Gender Females Race Asian* Cmax AUC Cmax AUC Adjustment not required Adjustment not required Change relative to reference *Compare to Caucasian 10 OVERDOSAGE 10.1 Human Experience In premarketing clinical studies involving 2905 patients, accidental or intentional overdosage of LATUDA was identified in one patient who ingested an estimated 560 mg of LATUDA. This patient recovered without sequelae. This patient resumed LATUDA treatment for an additional two months Management of Overdosage Consult a Certified Poison Control Center for up-to-date guidance and advice. There is no specific antidote to LATUDA, therefore, appropriate supportive measures should be instituted and close medical supervision and monitoring should continue until the patient recovers. Cardiovascular monitoring should commence immediately, including continuous electrocardiographic monitoring for possible arrhythmias. If antiarrhythmic therapy is administered, disopyramide, procainamide, and quinidine carry a theoretical hazard of additive QT-prolonging effects when administered in patients with an acute overdose of LATUDA. Similarly, the alpha-blocking properties of bretylium might be additive to those of LATUDA, resulting in problematic hypotension. Hypotension and circulatory collapse should be treated with appropriate measures. Epinephrine and dopamine should not be used, or other sympathomimetics with beta-agonist activity, since beta stimulation may worsen hypotension in the setting of LATUDA-induced alpha blockade. In case of severe extrapyramidal symptoms, anticholinergic medication should be administered. Gastric lavage (after intubation if patient is unconscious) and administration of activated charcoal together with a laxative should be considered. The possibility of obtundation, seizures, or dystonic reaction of the head and neck following overdose may create a risk of aspiration with induced emesis. Manufactured for: Sunovion Pharmaceuticals Inc. Marlborough, MA USA For Customer Service, call For Medical Information, call To report suspected adverse reactions, call R0X LATUDA is a registered trademark of Dainippon Sumitomo Pharma Co. Ltd. Sunovion Pharmaceuticals Inc. is a U.S. subsidiary of Dainippon Sumitomo Pharma Co. Ltd Sunovion Pharmaceuticals Inc.

7 The DSM-5 debuts in May! Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) American Psychiatric Association COMING MAY 2013! This new edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5 ), used by clinicians and researchers to diagnose and classify mental disorders, is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research. The criteria are concise and explicit, intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings inpatient, outpatient, partial hospital, consultation-liaison, clinical, private practice, and primary care. New features and enhancements make DSM-5 easier to use across all settings: The latest findings in neuroimaging and genetics have been integrated into each disorder along with gender and cultural considerations. The revised organizational structure recognizes symptoms that span multiple diagnostic categories, providing new clinical insight in diagnosis. Specific criteria have been streamlined, consolidated, or clarified to be consistent with clinical practice. Dimensional assessments for research and validation of clinical results have been provided. Both ICD-9-CM and ICD-10-CM codes are included for each disorder. Available at the APA Annual Meeting. ALSO COMING MAY 2013! The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most comprehensive, current, and critical resource for clinical practice available to today s mental health professionals ,000 pages ISBN Hardcover $ Item # ,000 pages ISBN Paperback $ Item #2555 Coming Summer 2013! Pre-order or call Explore the DSM-5 Collection of related titles The First and Last Word in Psychiatry Order Online: Phone: appi@psych.org Fax: % Discount For American Psychiatric Association Members! 25% Discount For APA Members-in-Training!

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9 Editors: Deborah Hales, M.D., and Mark Hyman Rapaport, M.D. The Best System in Psychiatry for Maintenance of Certification Self-Assessment Performance in Practice Lifelong Learning FOCUS is the best resource for: Maintenance of Certification Each issue offers one topic area in depth, and the entire field is covered in a four year cycle in the complete set. Topics are based on the recertification outline of the ABPN. Lifelong Learning For each featured topic, experts in the field select the most important developments and present them in that issue. A CME quiz is provided for each issue, allowing you to earn 5 CME credits. Self-Assessment Each fall subscribers receive a 120-question, multiple choice selfassessment exam with a critique and reference companion available on completion of the exam for an additional 24 CME credits. The exam can be taken online or on paper. Receive information on how you perform in comparison to others taking the test and privately measure your knowledge against that of your peers. FOCUS Performance in Practice (PIP) Clinical Modules Four PIP Modules, approved by ABPN for the clinical chart review component of MOC Part IV, are included in a subscription to FOCUS. Screening of Adults with Substance Use Disorder; Assessment and Treatment of Adults with Substance Use Disorder, Assessment and Treatment of Adults at Risk for Suicide and Suicide Related Behaviors, and The Assessment Tool for the Care of Patients with a Diagnosis of Schizophrenia are easy to use, paper-based PIP Modules. Completion of three stages of a PIP Module provides 20 additional CME credits and qualifies as a completed MOC Part IV activity. FOCUS updates you in core clinical areas: Volume VIII (2010): Psychotherapy; Personality and Temperament; Genetics and Genomics; Psychopharm acology: Treatment Resistant Disorders Volume IX (2011): Addiction Psychiatry; Bipolar Disorder; Professionalism and Quality Measures in Psychiatry; Anxiety Disorders Volume X (2012): Womens Mental Health; Schizophrenia; Child and Adolescent Psychiatry; Depression Volume XI (2013): Geriatric Psychiatry; Personality Disorders; Posttraumatic Stress Disorder and Traumatic Brain Injury; Integrated Care and Psychosomatic Medicine With your paid subscription, you ll also get unlimited online access to all past volumes at no extra charge. (CME for past volumes not included.) FOCUS gives you the opportunity to earn up to 44 or more AMA PRA Category 1 Credits TM per year. The American Board of Psychiatry and Neurology has reviewed FOCUS: The Journal of Lifelong Learning in Psychiatry and the FOCUS Self-Assessment Examination and has approved this program as part of a comprehensive lifelong learning and self-assessment program, which is mandated by the ABMS as a necessary component of maintenance of certifi cation. The American Board of Psychiatry and Neurology has reviewed the FOCUS Performance in Practice Modules: Screening for Adults with Substance Use Disorder; Assessment and Treatment of Adults with Substance Use Disorder, Assessment and Treatment of Adults at Risk for Suicide and Suicide Related Behaviors, and The Assessment Tool for the Care of Patients with a Diagnosis of Schizophrenia has approved each of these modules for ABPN MOC Part IV (clinical module) requirements. The FOCUS Self-Assessment Examination is approved for up to 20 hours of continuing professional development per year under Section 3 of the Maintenance of Certifi cation program of the Royal College of Physicians and Surgeons of Canada. The American Psychiatric Association (APA) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The American Psychiatric Association designates the FOCUS enduring material for a maximum of 44 AMA PRA Category 1 Credits TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. One-Year Prices: U.S. APA Members: $347 International Member: $436 APA MIT (Online Only): $112 U.S. Non-Member price: $557 International Non-Members: $645 Order online: The First and Last Word in Psychiatry American Psychiatric Publishing focus.psychiatryonline.org Phone: appi@psych.org Priority Code AH1238R Find us on and

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11 The American Journal of PSYCHIATRY Official Journal of the American Psychiatric Association Edited by Robert Freedman, M.D. 4 of Journal Watch Psychiatry s 10 Top Stories of 2012 appeared in AJP! No other journal had multiple appearances! The American Journal of Psychiatry (AJP) has an Impact Factor of according to the 2011 Journal Citation Reports (Thomson Reuters, 2012), placing it 2nd among the 129 journals in psychiatry while still remaining the far-and-away leader in total citations. PSYCHIATRIC SERVICES The Highest-Ranked Mental Health Journal in Health Policy and Services The latest impact factors are out! Of 62 journals in JCR s* Health Policy and Services Category, Psychiatric Services ranks higher than any other mental health journal! * Journal Citation Reports (Thomson Reuters, 2012) Latest IMPACT FACTOR ! The American Journal of Psychiatry is also the #2 journal in psychiatry in terms of immediacy according to Thomson Scientific s Immediacy Index. This important performance metric is calculated by dividing the number of citations to articles published in a given year by the number of articles published in that year. A poll conducted by the BioMedical & Life Sciences Division of The Special Libraries Associaton identified the 100 most influential journals in all of Biology & Medicine over the last 100 years. The American Journal of Psychiatry was among those honored, the only psychiatry/ psychology journal represented. No other psychiatric journal reaches more psychiatrists with greater impact or immediacy than the one the overwhelming majority of psychiatrists considers essential: AJP. ISSN X ajp.psychiatryonline.org To order a subscription, visit One low price covers your print and online subscription. * $98.00 APA member print and online subscription. $54.00 APA member online-only subscription. Order your subscription at * Includes APA International Members The First and Last Word in Psychiatry Priority Code AH1303 The First and Last Word in Psychiatry Subscribe today, visit or call Customer Service at Priority Code AH1263-PN Introducing the APA Annual Meeting App! NOW AVAILABLE Get 24-hour access to unique, on-the-go meeting information, maps, and networking. Downloading the App is Easy! For iphone, ipod Touch, and ipad users: From your handheld device, go to the itunes App Store and search the association s full name or acronym. Click on the free button, which will take you to the install screen. APA 2013 Scan here using your device s barcode scanner application for easy download. For BlackBerry, Android, and all other web-enabled smartphones and tablets: Point your device s web browser to m.core-apps.com/tristar-apa13. On this web-based mobile site, you will be directed to the proper download version for your device type. Supported by Sunovion Pharmaceuticals Inc., the APA Annual Meeting App is compatible with iphone, BlackBerry, and Android smartphones, as well as ipad and most tablets.

12 PSYCHIATRIC NEWS Copyright 2013, American Psychiatric Association Psychiatric News, ISSN , is published bi-weekly on the first and third Friday of each month by the American Psychiatric Association, 1000 Wilson Boulevard, Arlington, Va Periodicals postage paid at Arlington, Va., and additional mailing offices. Postmaster: send address changes to Psychiatric News, APA, Suite 1825, 1000 Wilson Boulevard, Arlington, Va Online version: ISSN Contents 7 Subscriptions U.S.: individual, $123. International: APA member, $167; nonmember, $184. Single issues: U.S., $24; international, $41. Institutional subscriptions are tier priced. For site licensing and pricing information, call (800) or institutions@psych.org. Officers of the Association Dilip Jeste, M.D., President Jeffrey Lieberman, M.D., President-elect David Fassler, M.D., Treasurer Roger Peele, M.D., Secretary Scott Benson, M.D., Speaker of the Assembly James H. 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Professional News 10 Mild Neurocognitive Disorder Added as DSM-5 Diagnosis The addition of mild neurocognitive disorder to Section II of the diagnostic manual reflects recent research showing that pathological changes and signs of impairment may appear years before diagnosis. 12 APA Answers Questions About Insurance Implications of DSM-5 Psychiatrists wondering how revisions to diagnostic criteria might affect insurance reimbursement have a new resource for answers. Association News 13 APA Fellows Reach Out to Minority Communities A 40th-anniversary video shows innovative work done by residents in the APA/ SAMHSA Minority Fellowship in settings as diverse as barbershops and primary care clinics. Legal News 16 Budgets Benefit When Mentally Ill People Have Alternatives to Jail When individuals become involved in the criminal justice system, costs paid by a state s mental health department to treat them rise dramatically. 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13 8 Psychiatric news May 3, 2013 Life Often Begins at 50 by Dilip Jeste, M.D. My presidential theme for the past year has been Pursuing Wellness Across the Lifespan. How does well-being change across the lifespan? The usual notion is that quality of life is high during the first half of life, and then, starting at midlife, it follows a progressively downhill course. Surprisingly, however, a number of recent studies across the world have demonstrated a U-shaped curve of psychological well-being and happiness from age 18 through 85 (see graph). Subjective feeling of well-being is high at the beginning of our adult life, then diminishes progressively until it hits rock bottom in middle age, producing the so-called midlife crisis, but then starts to rise Elderly s Well-Being Mirrors Youth s Well-being High Low Age Source: Blanchflower DG, Oswald AJ. Soc Sci Med 66: , 2008; Jeste DV, et al., Am J Psychiatry 70:188-96, 2013 again. Astonishingly, the level of happiness in the early 80s is similar to that in the early 20s. The increase in happiness after age 50 occurs even as physical health, cognitive function, and fertility decline. Notably, perfect physical health is neither necessary nor sufficient to feel happy as we grow older. Our recent communitybased study showed a paradox of aging: physical health and some aspects of cognitive function (for example, working memory) decline with age, while happiness, mental health, and interpersonal relationships improve. What are the possible explanations for this U-shaped curve? The midlife crisis is typically attributed to factors such as the stress of being a sandwich generation, having the dual responsibility of caring for young children as well as aging parents. Other factors include beginning concerns about retirement, physical illnesses, and mortality, along with a disappointing realization of one s failed ambitions. People respond to this phase in different ways that are believed to lead to greater happiness after age 50 some change their jobs and/or partners and/or relocate, while others change their attitudes. The latter include a greater acceptance of one s physical limitations, contentedness with past accomplishments, reduced preoccupation with peer pressure, and a more realistic appraisal of one s strengths and limitations. There are also other positive changes with aging. Older employees tend to be hard working, conscientious, reliable, and collegial, and they take fewer sick days off than their younger counterparts. Studies show that, compared with youth, older adults make better decisions that require experience, are emotionally more stable, and become less-impulsive risk takers. An excellent example is Chesley Sully Sullenberger, who gained international acclaim when he, at age 58, successfully landed U.S. Airways Flight 1549 in the Hudson River after both its engines had failed and saved the lives of all 155 passengers on board. He credited his performance in the face of a looming disaster to age-related wisdom. It might be that for many years I ve been making small, regular deposits in my bank of experience, education, and training. And on January 15, 2009, the balance was sufficient so that I could make a very large withdrawal, Sullenberger said in an interview. Intriguingly, a recent study found evidence that a U-shaped pattern of wellbeing was present even in chimpanzees and orangutans, based on the reports by these great apes individual caretakers in zoos and other protected areas. Thus, better well-being in older age might be rooted, in part, on biological changes in the brain. This theory is indirectly supported by recent neuroscience research demonstrating neuroplasticity of aging. New synapses, and in some regions, even new neurons, can form in older brains if there is optimal physical and psychosocial stimulation. Age-related well-being is also associated with other positive personality traits such as resilience, optimism, and social engagement. These traits are partly inherited, but also can be enhanced through behavior and environment. Research has demonstrated that optimistic, resilient, and socially engaged people live longer, happier lives, with lower risk of developing heart disease, depression, and dementia, compared with people who have lower levels of those traits. Positive traits probably serve to counteract the negative effects of various stresses on successful aging. Old age is not necessarily the age for retirement from cognitive, social, and physical activities and certainly not from life but can be a time for new careers and new ventures. There is a variety of role models of successfully aging individuals. Below are examples of a few well-known physicians. Some physicians continue their professional life in old age that is, they do not retire from their work. Aaron Beck, emeritus professor of psychiatry at Penn, now in his early 90s, is the father of cognitive-behavioral therapy and winner of the 2006 Lasker Clinical Medical Research Award. He continues to write and conduct research. He recently published a new book with his daughter and was an amazingly engaging speaker at APA s 2012 annual meeting. Some physicians continue their clinical work. Michael DeBakey, a pioneering heart surgeon, performed more than 60,000 heart surgeries before putting down his scalpel at age 90. He said that his secret to successful aging was constant intellectual challenge, good salads, and four to five hours of sleep at night. Other physicians turn to community service. Shigeaki Hinohara, a centenarian, chairs the Board of Trustees of an international hospital and a nursing school in Tokyo. He has published several books since his 75th birthday, including Living Long, Living Good, which has sold over a million copies. He founded the New Elderly Movement and does voluntary work seven days a week. Finally, there are inspiring examples of individuals who fought physical and mental illnesses and increased their creativity in later life. William Carlos Williams was a pediatrician from Rutherford, N.J., who loved to write poetry. He suffered from major depression and later developed recurrent strokes that led to his retirement. Williams dedicated his remaining years to writing poetry. He wrote his most mature, evocative poetry after retirement, for which he received the Pulitzer Prize, National Book Award, and Gold Medal for Poetry. Data on well-being across the lifespan in people with serious mental illnesses are very limited. However, several longitudinal investigations, including ours, show that among community-dwelling persons with chronic schizophrenia, mental health improves in later life, provided they receive appropriate health care and psychosocial support. While survivor bias (that is, the sickest people die young and don t make it into old age) is a partial explanation, it certainly is not the whole story. In summary, while aging of body tissues is inevitable, mental deterioration is not. A positive attitude, a rational mix of optimism and realism, resilience, engagement in stimulating physical, cognitive, and social activities along with a dose of good luck biologically that is the prescription for successful aging after 50. A glass of pinot noir is optional! PN

14 members in the news 9 Psychiatrist Helps Ensure Future Of Psychosomatic Medicine Philip Muskin, M.D., relishes the challenges of working with severely medically ill patients and instills his love of the field in young psychiatrists. by Eve Bender A s a child, the tagline for the favorite TV show of Philip Muskin, M.D., could aptly describe the most poignant aspects of his future career as a clinician and educator in psychosomatic medicine: Man, woman, birth, death, infinity. Ben Casey was a medical-drama series airing in the early 1960s starring Vincent Edwards as a determined and idealistic surgeon. Muskin, having survived a bout with polio at a young age, was inspired by the lifesaving skills of that heroic TV doctor. His trajectory toward psychiatry was further fueled by the influence of his father, a psychologist whose bookshelves were filled with Sigmund Freud s writings. I found Freud fascinating, Muskin told Psychiatric News. The idea of helping people to understand themselves was very appealing to me. After studying depth perception at the New School for Social Research as a graduate student, Muskin completed medical school at New York Medical College, followed by an internship in internal medicine at the Metropolitan Hospital Center in New York and a psychiatry residency at the New York State Psychiatric Institute. He received psychoanalytic training at Columbia University Psychoanalytic Center. Muskin was also awarded a National Institute of Mental Health fellowship in consultation-liaison psychiatry. Today, as a professor of clinical psychiatry and chief of the consultationliaison psychiatry service at Columbia University Medical Center, he treats patients with physical illnesses who may have psychiatric disorders or are struggling with life-threatening conditions and teaches residents to do the same. He also maintains a private practice. Not for the Faint of Heart While he acknowledged that it is not work for the faint of heart, It s rewarding to walk onto a medical or surgical ward and be part of the team, Muskin said. While some of his patients may have a combination of general medical and psychiatric diagnoses schizophrenia and pneumonia or borderline personality disorder and diabetes, for instance some may need help coping with end-of-life issues. For example, Muskin and his residents recently saw a patient in the intensive care unit who at age 48 had just been told she had only months to live. She knows she is going to die. She has a 21-year-old daughter in her final year of college and wants to make sure that her daughter will be okay. Muskin said his job at that point is to sit with the patient as she faces the painful emotions inherent in a terminal diagnosis. I teach my residents that it s OK to cry with their patients and that this work is often emotionally taxing, he said. He also began working with a young woman with cystic fibrosis who received a lung transplant, and he has helped her cope with anxiety and other issues related to her significant medical issues. When one of the psychiatry residents rotating through the consultation-liaison service is asked to see a patient on a medical or surgical unit, the patient may not be expecting to see a psychiatrist, Muskin noted, so he teaches the residents to ask what, if anything, the referring doctor has told the patient about the resident s visit. Many times, the answer is I didn t tell the patient anything, because the physician does not know how to raise the issue of potential mental health problems with their patients, he said. Ideally, the referring physician tells the patient that a visit from a psychiatrist can ensure that he or she is getting the best medical care possible, and Muskin is often able to help his nonpsychiatric colleagues have this conversation with their patients who need a psychiatric consultation. Philip Muskin, M.D., is dedicated to ensuring that the next generation of psychiatrists has access to funded fellowships in psychosomatic medicine. To this end, he is raising money from members of the Academy of Psychosomatic Medicine for the Webb Fellowship Program. Fundraising Is Crucial Activity In addition to educating the next generation of psychiatrists in this field, Muskin goes the extra mile to secure the future of the subspecialty as chair of the Board of Directors of the Foundation of the Academy of Psychosomatic Medicine (fapm), a 501(c)3 charitable organization. The academy was founded 50 years ago to promote excellence in clinical care for patients with coexisting psychiatric and general medical conditions by promoting research and education in psychosomatic medicine. The reality is that there is very little federal funding for trainees in psychosomatic medicine, Muskin said, and Psychiatry Residents Honored T he American College of Psychiatrists recognized the 2013 recipients of its prestigious Laughlin Fellowship at the college s annual meeting in February. Each year, the college selects 10 residents deemed likely to make a significant future contribution to the field of psychiatry. Alexis Aplasca, M.D., of Honolulu is a chief resident at the University of Hawaii combined training program in pediatrics, adult psychiatry, and child and adolescent psychiatry. Alexis Armenakis, M.D., of San Francisco is a chief resident at the University of California, San Francisco. Sepideh N. Bajestan, M.D., Ph.D., of Palo Alto, Calif., is a fourth-year resident in psychiatry at Stanford University. Zhanna (Jane) Elberg, M.D., of Photo courtesy of Philip Muskin, M.D. pharmaceutical-industry funding for research and fellowships across psychiatry and medicine in general is also dwindling. This means that much of the funding for fellowships and research in psychosomatic medicine must come from private donations. Early Career Psychiatrists Supported Each year, fapm leaders hold events at the annual meeting of the Academy of Psychosomatic Medicine to raise funds for competitive fellowships to support early career psychiatrists in psychosomatic medicine. In addition, there is the 100% Campaign, which tries to raise $100 from each member of the academy toward this goal and has raised about $60,000 so far. The funding has supported the Webb Fellowship Program, in which early career psychiatrists receive a small award to support their attendance at the academy s annual meeting and to support mentorship as they conduct research on psychosomatic medicine. However, the awards are relatively small, and Muskin is interested in approaching large charitable organizations to urge them to match existing funds raised by the foundation to support the fellowships on a permanent basis. Supporting our colleagues is part of what we do as psychiatrists, Muskin said. All of us have been lucky enough to have trained in psychiatry and to practice shouldn t we want the same for the next generation of psychiatrists? In addition to his other professional activities, Muskin chaired the Scientific Program Committee for the APA annual meeting from 2000 to PN Information about the Academy of Psychosomatic Medicine s fellowship program is posted at webb-fship.shtml. Information about the Foundation of the Academy of Psychosomatic Medicine, including how to donate, is available from Muskin at prm1@columbia. edu. Amherst, N.Y., is completing her final year of a child and adolescent psychiatry fellowship at the University at Buffalo School of Medicine and Biomedical Sciences. Carl Erik Fisher, M.D., of Brooklyn, N.Y., is a fourth-year resident in psychiatry at Columbia University and the New York State Psychiatric Institute. Matthew S. Kayser, M.D., Ph.D., of Philadelphia is a fourth-year resident in psychiatry at the Perelman see Residents on page 13

15 10 Psychiatric news May 3, 2013 professional news Mild Neurocognitive Disorder Added to DSM The diagnosis reflects an attempt to move upstream toward identifying and diagnosing Alzheimer s and other neurocognitive disorders earlier. The articles on this and the facing page are part of a series on the differences between DSM-IV and DSM-5. The series will end later this month, when the manual is published. by Mark Moran M ild neurocognitive disorder, previously in the appendix of DSM-IV, will appear in Section II of DSM-5 in the chapter on neurocognitive disorders, recognizing the many patients seen by clinicians who do not meet DSM- IV criteria for dementia but who are nevertheless clinically impaired. The inclusion of mild neurocognitive disorder in the neurocognitive disorders chapter of the revised manual reflects a body of research emerging since DSM- IV demonstrating that individuals with Alzheimer s and other neurocognitive disorders may begin showing mild signs of cognitive impairment years before their diagnosis and may have neuropathological changes even before the onset of mild symptoms. In recent years, there has been an emergence of a new construct driven by neurology but cutting across the entire field of neurocognitive disorders, but especially Alzheimer s, indicating that we need to move upstream in terms of making a diagnosis, work group chair Dan Blazer, M.D., Ph.D., said in an interview. People Preorder Your DSM-5 Now! DSM-5 and related titles may be preordered at org/searchcenter/pages/default. aspx?k=2555. Also, attendees at the 2013 annual meeting in May will have an exclusive opportunity to purchase DSM-5 before it goes on sale to the public. The manual will be available in the American Psychiatric Publishing Bookstore in the Exhibit Hall in the Moscone Convention Center. Those who come to the bookstore on Saturday, May 18, from 4 p.m. to 5 p.m. can meet the DSM-5 Task Force chairs and receive a free gift with purchase. (See the box on page 7 for meeting registration information.) Whether buying online or in person, APA members are eligible for a discount. are coming into our offices not meeting criteria for a major neurocognitive disorder but who are clearly impaired. These are people who can live alone, but who are struggling with it, who can get to the store on their own but may need a map. These are individuals who, if you submit them to neuropsychological tests, clearly have abnormalities, he continued. They are not dramatically off the scale, but tests provide objective evidence for subjective clinical impressions. And there are emerging studies of people with Alzheimer s showing neuropathological changes even before symptoms become apparent at all. The chapter on neurocognitive disorders is the 17th of Section II in DSM- 5, to be available later this month. The 18th chapter on personality disorders includes no changes to DSM-IV criteria; however, a dimensional approach to the assessment of personality and the diagnosis of personality disorders is included in Section III (see page 11). And the 19th chapter, on paraphilic disorders, contains no alterations to criteria, but does entail some important conceptual reformulations (see article below). In an interview earlier this year with Psychiatric News, DSM-5 Task Force Chair David Kupfer, M.D., outlined some of the overarching conceptual ideas that have informed the development of diagnostic criteria and the organization of the text. These include incorporation of a developmental approach to psychiatric disorders, a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders, harmonization of the text with ICD, and integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates (Psychiatric News, January 18). DSM-5 has three sections: Section I gives an introduction with instructions on how to use the manual; Section II outlines the categorical diagnoses according to a revised chapter organization that eliminates the multiaxial system; and Section III includes conditions requiring further research before their consideration as formal diagnoses, as well as cultural formulations and other information. Kupfer said the classification of disorders is largely harmonized with the World Health Organization s International Classification of Diseases (ICD) so that the DSM criteria sets are more parallel with the proposed ICD-11 (see page 12). There are now two major diagnostic categories in the chapter on neurocognitive disorders: mild neurocognitive disorder and major neurocognitive disorder Key Points Mild neurocognitive disorder, previously included in the appendix of DSM-IV, is intended to describe individuals who have cognitive impairment but do not meet previous DSM-IV criteria for dementia. Its inclusion in Section II reflects the movement within the Alzheimer s community toward earlier diagnosis and treatment. The DSM-IV diagnosis of dementia is subsumed under the newly named entity major neurocognitive disorder. Criteria for mild and major neurocognitive disorder include etiological subtypes having their own separate criteria: Alzheimer s disease neurocognitive disorder (NCD), vascular NCD, frontotemporal NCD, Lewy bodies NCD, traumatic brain injury NCD, Parkinson s disease NCD, HIV infection NCD, substance-/medication-induced NCD, Huntington s disease NCD, prion disease NCD, NCD due to another medical condition, and unspecified NCD. (the latter replaces dementia of DSM- IV). And for each of these there are etiological subtypes, also having their own separate criteria: Alzheimer s disease neurocognitive disorder (NCD), vascular NCD, frontotemporal NCD, Lewy bodies NCD, traumatic brain injury NCD, Parkinson s disease NCD, HIV infection NCD, substance-/medication-induced NCD, Huntington s disease NCD, prion disease NCD, NCD due to another medical condition, and unspecified NCD. Blazer acknowledged a possible downside to the category of mild neurocognitive disorder and cautioned against arbitrary application of the diagnosis. Individuals wishing to enter a residential retirement community can sometimes be denied entry if they carry this diagnosis, he said. But the quest among researchers and clinicians in the Alzheimer s field as well as family and patient advocates for earlier diagnosis and treatment made inclusion of the diagnosis in Section 2 very compelling. He added that inclusion may help to spur development of better treatments. In the Alzheimer s field, where it is goes by the name of mild cognitive impairment, this is a train that has already left the station, Blazer said. Our work group included a neurologist [Ronald Peterson, M.D, Ph.D.], who informed us that if we did not have this category, we would be very much behind what is going on in the mainstream of Alzheimer s treatment and research. PN A fact sheet and two video interviews with Daniel Blazer, M.D., Ph.D., on mild neurocognitive disorder can be accessed by scanning the QR code with your smartphone or going to psychiatry.org/dsm5. DSM to Distinguish Paraphilias From Paraphilic Disorders The distinction between paraphilias and disorders reflects the idea that many people may practice atypical sexual behaviors without meriting a diagnosis of mental illness. by Mark Moran I mportant conceptual changes to the chapter on paraphilic disorders will appear in DSM-5, though there are few alterations of the criteria. Most apparent to clinicians will be the distinction between paraphilias defined as atypical sexual practices and paraphilic disorders, which include distress or impairment in functioning. Specific criteria for paraphilic disorders are not changed except for the addition of specifiers for in remission or in a controlled environment to indicate course of illness; the latter specifier would be used, for instance, in the case of someone with a pedophilic disorder who no longer engages in sexual activity with children because the individual is incarcerated. Sub-work-group chair Ray Blanchard, Ph.D., told Psychiatric News that the distinction within the chapter between paraphilias and paraphilic disorders is a crucial one acknowledging that many people engage in atypical sexual practices, or paraphilias. Blanchard explained that a paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by see Paraphilias on page 26

16 DSM Section Contains Alternative Model for Evaluation of PD Clinicians are urged to avail themselves of the new dimensional model of personality disorder evaluation and should find it easy and intuitive to use. by Mark Moran C linicians will see no change in the criteria for personality disorders (PD) in Section II of DSM-5, to be available later this month. But they will find an alternative model for evaluation of PD using a dimensional approach and measures of severity in Section III of the manual. The latter section is reserved for diagnostic material that may need more research and/or more time for clinicians to become acquainted with it, before being included as formal criteria in Section II. John Oldham, M.D., a past APA president and a member of the Work Group on Personality Disorders, told Psychiatric News that the model of evaluation and diagnosis included in Section III what he called a hybrid of the categorical approach of earlier editions and a new dimensional understanding of personality is founded on abundant research on personality traits. He added that the dimensional framework is also highly relevant for other areas of psychiatric diagnosis. The approach to personality disorders in the alternative model in Section III embodies some principles that have guided development of DSM-5 from its beginnings: an attempt to develop a model of diagnosis that would address the considerable overlap of symptoms across disorders and the overuse of not otherwise specified (NOS) as in DSM-IV. From the beginning of the development process for DSM-5, the personality disorders were identified as a place where we needed to move beyond the categorical diagnostic system of discrete disorders in DSM-IV toward a more dimensional system, Oldham said in an interview. Personality types, traits, and disorders are on a continuous spectrum, much like blood pressure and hypertension. Too much of a useful, adaptive trait may become a problem. Oldham said the work group sought to retain the most familiar and useful aspects of the categorical system to which clinicians were accustomed. The group assembled a large research base to evaluate the construct validity of 10 personality disorders that had professional news been included in DSM-IV, and they recommended retaining the following six: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal. The group then created the category called personality disorder trait specified (PD-TS), which applies to patients who meet the general criteria for a personality disorder but do not have one of the six specified disorders. PD-TS would replace the current PD-NOS category, with the advantage of being not just a PD diagnosis by exclusion, but one that identifies pathological trait profiles. (Using the trait specifiers, clinicians can note symptoms of those other DSM-IV disorders paranoid, schizoid, histrionic, and dependent that are not included as specified personality clinical disorders in the Section III alternative model of DSM-5.) Oldham said the work group then sought to clarify and simplify the personality disorders creating a uniform scheme for criterion A and criterion B Personality Disorders A new approach to the diagnosis of personality disorders was developed for DSM-5 to help address shortcomings of DSM-IV personality disorders (for example, overuse of the DSM-IV personality disorder not otherwise specified diagnosis). This alternate approach can be found in Section III, where it is provided for further research to determine whether it is potentially clinically useful and should be included in future editions of DSM. Since this alternate model still requires further study, an update of DSM-IV personality disorder criteria is provided in DSM-5 Section II. In the Section III alternate model, the revised A criterion for the general criteria for personality disorder has been developed on the basis of a literature review of reliable clinical measures of core impairments in personality functioning central to personality pathology. It has been validated as specific for semi-structured interview diagnoses of personality disorders in samples of over 2,000 patients and community subjects. These questions are from DSM-5 Self-Exam Questions: Test Questions for the Diagnostic Criteria, which may that would apply to all the disorders: criterion A describes impairment in self or interpersonal functioning, which is broken down into impairment in identity and self-direction (self) and empathy and intimacy (interpersonal functioning); criterion B describes pathological personality traits in five broad trait domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Finally, the alternate model in Section III includes a scale for measuring the level of impairment ranging from 0 (no impairment) to 4 (severe impairment). A diagnosis of one of the personality disorders would require at least a level 2 ( moderate ) category of impairment. The alternative model is intended to move toward a way of diagnosing disorders that fits the patient who comes to the clinician s office with a variety of presentations, rather than fitting the individual into a preconceived categorical scheme. Oldham also noted that in be preordered at SearchCenter/Pages/SearchDetail. aspx?itemid=62467 from American Psychiatric Publishing. The answers and rationales are posted at psychnews.org/pdfs/dsm-5_self_ Examination_QandA_4.pdf. The questions were developed under the leadership of Philip Muskin, M.D., a professor of clinical psychiatry at Columbia University College of Physicians and Surgeons. The book, available in August, contains 500 questions for all the categories of psychiatric disorders and includes Section III. 1. Which of the following best describes the diagnostic model proposed in the alternate model for personality disorders in DSM-5 to classify personality disorders? a) Categorical b) Dimensional c) Hybrid d) Polythetic e) Socratic 2. In addition to an assessment of pathological personality traits, DSM-5 requires an assessment of which of the 11 the DSM-5 field trials, the model was well received by clinicians and greatly preferred over that in DSM-IV. He added that what may seem, on the face of it, a complicated scheme is in fact far simpler than the categorical criteria for disorders in DSM-IV. Oldham urged clinicians to familiarize themselves with the model and to try using it as a helpful tool in assessing all patients; when they do, they will find it easy and intuitive, he said. Once people are familiar with it, they will use it prototypically that is, clinicians have a prototype or a picture in their head of what the average patient with, say, borderline personality looks like, he said. As with almost all disorders, you don t go through every criterion, but rather you listen and look for the symptoms that are most obvious and that guide you instinctively to the diagnosis that fits the patient. PN A fact sheet and audio interview on the alternative model for evaluation of personality disorders can be accessed by scanning the QR code with your smartphone or going to org/dsm5. following for a personality disorder diagnosis? a) Level of impairment in personality functioning b) Comorbidity with Axis I disorders c) Degree of introversion versus extroversion d) Stability of the personality traits over time e) Familial inheritance of specific traits 3. Which of the following is a domain of the DSM-5 trait model of personality? a) Neuroticism b) Extraversion c) Disinhibition d) Agreeableness e) Conscientiousness PN DSM-5 Track: Don t Miss It APA s 2013 annual meeting is offering a special track of sessions on DSM-5 to help clinicians master the differences between DSM-IV and DSM-5 and learn how to use the new and revised criteria. A listing of sessions in the DSM-5 track is posted at psychiatryonline.org/newsarticle. aspx?articleid=

17 12 Psychiatric news May 3, 2013 Professional News Insurance Implications Of DSM-5 The impending publication of DSM-5 has led many psychiatrists to ask how it will impact reimbursement and continuity of care. T he fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), whose official publication date is May 22, has been developed to facilitate a seamless transition into immediate use by clinicians and insurers to maintain continuity of care. The revised manual represents a step forward in more precisely identifying and diagnosing mental disorders. To help ensure ease of use, DSM-5 will continue to use statistical codes DSM-5 Goes Mobile The DSM-5 app allows users to drill down into the criteria quickly through either a navigation menu or keyword search. by Jennifer Walsh T his June, American Psychiatric Publishing will launch the DSM-5 Diagnostic Criteria Mobile App. The app available for both ios and Android devices provides onthe-go, offline access to the DSM-5 diagnostic criteria. From the convenience of a smartphone or tablet, users of the DSM-5 app will be able to search by disorder, symptom, or ICD code; view the criteria in detail; and bookmark content for easy reference. The use of mobile apps in clinical practice continues to grow dramatically. Of the 300 doctors polled in a recent study conducted by comscore/ Symphony Health Care Professional Measurement Solutions, 60 contained in the U.S. Clinical Modifications (CM) of the World Health Organization s (WHO s) International Classification of Diseases (ICD). The ICD-9-CM contains the internationally approved statistical codes for all medical diseases or disorders but does not contain detailed descriptions of how to diagnose these conditions. The APA Office of Healthcare Systems and Financing, along with APA s DSM staff, will be meeting with representatives from the insurance industry in coming weeks to help ensure a seamless transition to use of DSM-5. The expectation is that the insurance industry s transition to DSM-5 can be made by December 31. Below are frequently asked questions that APA has received whose answers are pertinent to insurers and clinicians. Answers were prepared by the APA Office of Research. Q A When can DSM-5 be used for insurance purposes? Since DSM-5 is completely compatible with the HIPAA-approved ICD-9-CM coding system now in use by insurance companies, the revised criteria for mental disorders can be used for diagnosing mental disorders immediately upon release. However, the change in format from a multiaxial system in DSM-IV-TR may result in a brief delay while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes. Q A How will the previous multiaxial conditions be coded? DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Although a single-axis recording procedure was previously used for Medicare and Medicaid reporting, some insurance companies required clinicians to report on the status of all five DSM-IV-TR axes. Contributing psychosocial and environmental factors or other reasons for visits are now represented through an expanded selected set of ICD-9-CM V codes and, from the forthcoming ICD- 10-CM, Z codes. These codes provide ways for clinicians to indicate other conditions or problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis, or treatment of a mental disorder (such as relationship problems between patients and their intimate partners). These conditions may be coded along with the patient s mental and other medical disorders if they are a focus of the current visit or help to explain the need for a treatment or test. Alternatively, they may be entered into the patient s clinical record as useful information on circumstances that may affect the patient s care. Q On October 1, 2014, the United States adopts ICD-10-CM as its standard coding system. How will diagnoses be coded then? A DSM-5 contains both ICD-9-CM codes for immediate use and ICD- 10-CM codes in parentheses. The inclusion of ICD-10-CM codes facilitates a cross-walk to the new coding system that will be implemented on October 1, 2014, for all U.S. health care providers and systems, as recommended by the Centers for Disease Control and Prevention s National Center for Health Statistics (CDC-NCHS) and the Centers for Medicare and Medicaid Services (CMS). This feature will eliminate the need for separate training on ICD-10-CM codes for mental disorders that is now being offered for all other diseases/disorders by other medical societies and vendors to prepare for the 2014 implementation. Q With the removal of the multiaxial system in DSM-5, how will disability and functioning be assessed? A DSM-5 includes separate measures of symptom severity and disability for individual disorders, rather than the Global Assessment of Functioning (GAF) scale that combined assessment of symptom severity, suicide risk, and social functioning into a single global assessment. This change is consistent with WHO recommendations to move toward a clear conceptual distinction between the disorders contained in the ICD and the disabilities resulting from disorders, which are described in the International Classification of Functioning, Disability, and Health (ICF). The World Health Organization Disability Assessment Schedule (WHO- DAS 2.0) is provided in Section III of DSM-5 as the best current method for measuring disability, and various disorder-specific severity scales are included in Section III and online. The WHO-DAS 2.0 is based on the ICF and is applicable to patients with any health condition, thereby bringing DSM-5 into greater alignment with other medical disciplines. While the WHO-DAS was tested in the DSM-5 field trials and found to be reliable, it is not being recommended by APA until more data are available to evaluate its utility in assessing disability status for treatment planning and monitoring purposes. Q Sometimes different disorders or subtypes share the same diagnostic code. Is this an error? A No. It is occasionally necessary to use the same code for more than one disorder. Because the DSM-5 diagnostic codes are limited to those contained in the ICD, some disorders must share codes for recording and billing purposes. For a few new disorders, such as disruptive mood dysregulation disorder, the only ICD-9-CM code available for DSM-5 was a Not Otherwise Specified (NOS) code from DSM-IV (mood disorder NOS ). For ICD- 10-CM the code will be F34.8, which is now mood disorder, other specified. APA will be working with CDC-NCHS and CMS to include new DSM-5 terms in the ICD-10-CM and will inform clinicians and insurance companies when modifications are made. percent of respondents reported using mobile phones and 44 percent said they used tablets on a daily basis in the workplace. This increase in mobiledevice usage highlights a need for apps that provide fast and easy access to information, better enabling physicians and other health care professionals to reference critical data throughout their work day. Designed to supplement DSM-5, the app extracts the most essential components of DSM-5 and allows users to drill down into the criteria quickly through either a navigation menu or keyword search. The app serves as an invaluable resource for clinicians to efficiently navigate the diagnostic criteria as they integrate DSM-5 into their practice, study, or research. Those attending APA s 2013 annual meeting will have the chance to preview the app at the American Psychiatric Publishing Bookstore in the Exhibit Hall. The DSM-5 Diagnostic Criteria Mobile App can be purchased through the itunes store and Android market beginning June 1. PN see Insurance Implications on page 26

18 Fellowship s Good Works Highlighted in New Video A video marking the 40th anniversary of the APA/ SAMHSA Minority Fellowship Program shows how a small number of residents can impact thousands so profoundly. by Eve Bender A video presentation showcasing the initiatives of the APA/ SAMHSA Minority Fellowship Program is set to air at APA s 2013 annual meeting this month. The video highlights the innovative work of the fellows as it is conducted in locales as varied as barbershops and primary care clinics. The fellowship provides psychiatry residents with specialized training in culturally competent care and provides them with funds to reach out to minority populations in creative ways in an attempt to reduce mental health care disparities. The video is designed to pique interest in the fellowship and demonstrate how the program affects often marginalized minority communities all over the U.S., said Michelle Durham, M.D., M.P.H., in an interview with Psychiatric News. Durham is an APA/SAMHSA Minority Fellow and a child and adolescent psychiatry fellow at the Yale Child Study Center and pitched the idea of the video to other fellows and APA leaders last year. Durham worked closely with Let s Imagine Health, the company that Association news APA/SAMHSA Minority Fellows gather at their annual awards presentation and reception at last year s annual meeting. Shown in the front row are Melissa Maitland, M.D., Annelle Primm, M.D., Dilip Jeste, M.D., Marilyn King, Yasmin Owusu, M.D., and Shana Gage, M.D. Primm is director of APA s Office of Minority and National Affairs, and Jeste is APA president. produced and directed the video, and helped raise funding for it from the fellows and from APA s Office of Minority and National Affairs (OMNA). We hope the film will encourage students and trainees to consider applying for this fellowship, inspire viewers to get involved in their respective communities, and foster greater understanding of minority groups and the pressing mental health issues that affect them, Durham said. Barbers May Help Screen Clients The video is approximately 10 minutes long and features the work of five minority fellows who are interviewed on camera. One of the fellows featured in the video, Teo-Carlo Straun, M.D., is an addiction psychiatry fellow at Yale University and is using the fellowship funds to run a program he started in tandem with Mosaic, a nonprofit organization in Worcester, Mass. Straun serves as medical director of Barbershop Health Outreach Program, which screens clientele of participating barbershops in Worcester for mental illness, substance use disorders, and cardiovascular diseases. Barbers already have strong, trusting relationships with their clients, Straun said. Their clients are open with them and speak about news, politics, and what s going on in their own lives, Straun said. He worked with the local barbers so that they could effectively elicit information from their clients about diet, exercise, sleep, stress, and smoking, for instance. Due to the prevalent stigma surrounding mental health problems in African- American communities, Straun has the barbers ask questions about sleep, appetite, or other physical manifestations of mental health problems, he said. If during the course of the visit the barber learns that a client has a potential health problem, the barber will consult with Straun, who discusses whether to refer the client to one of several local health centers. Projects often fail because they have no funding, but the barbers volunteer to screen clients for free, Straun noted. Part of his training of the barbers is to emphasize to them that their jobs are not just to help their clients look their best, but to build trusting relationships with and empower their customers. Fellows Work With Immigrants Third- and fourth-year residents at Emory University s Department of Psychiatry and Behavioral Sciences will have the opportunity to work with immigrants and refugees in July as part of a cultural psychiatry elective at the International Medical Center at Grady, a primary care clinic, according to Nisha Shah, M.D., another of the fellows in the video. Shah is a PGY-4 psychiatry resident at Emory. If I did not have funding from the minority fellowship, I could not have created the fellowship for this program and have it survive to the point where it is now an elective being offered to third- and fourth-year residents, she said, nor would there be any initiative for working with this struggling but very resilient population. Yet another fellow, Beverly Du, M.D., a PGY-4 resident at Columbia University, will be spotlighted in the video as she describes the annual Global Mental Health Forum, which she launched with fellowship funds. The forum is a conference drawing health professionals from a variety of backgrounds and training to discuss issues in global mental health, Du explained. The funding has also enabled her to participate in research projects on developing mental health interventions for families in Brazil, focusing on the impact of immigration on children s mental health, she said. According to Annelle Primm, M.D., M.P.H., APA deputy medical director and head of OMNA, the fellows featured in the video have done excellent work exhibiting creativity and innovation in meeting the mental health needs of diverse and underserved populations. The fellowship has become a culture in which robust academic activity, mutual respect, and fruitful collaboration are valued. The program is truly a national treasure putting APA on the map as a developer of communityengaged psychiatric leadership. The video will be played during APA s 2013 annual meeting at the American Psychiatric Foundation benefit dinner, the National Minority Network breakfast, the alumni reception, and continuously on the APA channel at the Moscone Convention Center and at several annual meeting hotels. PN Residents continued from page School of Medicine at the University of Pennsylvania. Christina Tara Khan, M.D., Ph.D., of Palo Alto, Calif., is a first-year child and adolescent psychiatry community track fellow at Stanford University School of Medicine. George Loeffler, M.D., of San Diego, Calif., is a fourth-year resident in psychiatry in the Department of Mental Health at the Naval Medical Center in San Diego, where he is chief resident and a lieutenant in the U.S. Navy. Deepak Prabhakar, M.D., M.P.H., of Farmington Hills, Mich., is in his fifth year of postgraduate training and the second year of a child and adolescent psychiatry fellowship at the Detroit Medical Center/Wayne State University program. He is also the fellowship s chief resident. Arshya Vahabzadeh, M.D., of Atlanta is a third-year resident in psychiatry at Emory University School of Medicine. This summer he will become editor in chief of the American Journal of Psychiatry s Residents Journal. PN

19 14 Psychiatric news may 3, 2013 Association News Report on Health Care Reform Focuses on Psychiatrists Role The scope of health system change makes it difficult to know how systems will evolve in different regions of the country. by Mark Moran A comprehensive report on the role of psychiatry in health system reform, delivered last month to the APA Board of Trustees, emphasized the importance of emerging models of integrated or collaborative care. The extensive report the executive summary alone is 38 pages is the work of a special ad hoc work group on the role of psychiatry in health care, chaired by incoming APA Presidentelect Paul Summergrad, M.D. The report covers issues related to the rollout of the Affordable Care Act (ACA), but emphasizes that health care reform is broader than the ACA and includes multiple state, federal, and private patient-care delivery and payment initiatives. Common themes going forward in both the public and private sectors, according to the report, are these: Regardless of the adoption of particular clinical or reform models, the financial pressures for control of health care costs by federal, state, and employer payers will continue. New models of care delivery (with varying degrees of evidence to support them) are under development and/or being deployed. The triple aim of population health, measurement of quality and performance, and reduced cost of care will drive clinical system development. How care is measured and monitored (quality and performance measures) will be increasingly codified. Alternative payment methodologies will be developed and deployed. Patient-centered principles of care including medical homes will become common. Of particular importance to psychiatrists, other physicians, and policymakers is that there is considerable evidence that patients with psychiatric and substance use Paul Summergrad, M.D., oversaw the effort to prepare a comprehensive report on health care reform and draw up a list of recommendations for APA action. disorders suffer from high rates of medical comorbidity and markedly increased costs for their total medical care. Population Health a Focus So what might individual psychiatrists do to prepare? We should become familiar with these new models of integrated or collaborative care, Summergrad told Psychiatric News. We were asked by the Board to inventory developing models in the general-medical and public-sector settings and the evidence for their efficacy, which is what we focused on in our report. The forces converging around integrated or collaborative care are many including, most prominently, the pressure of budget deficits and increasing costs of care. More specifically, policymakers and some psychiatric pioneers in integrated care have focused on the high medical costs associated with general medical patients having comorbid psychiatric and substance use conditions. But the movement toward integrated care is also driven by more global trends in care redesign, especially a focus on population health, measurement of outcomes, use of electronic records, and the triple aim in improving overall quality. The latter is a framework developed by the Institute for Healthcare Improvement for optimizing health system performance by simultaneously pursuing three goals or aims : improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care. Integrated care was the theme of past APA President John Oldham, M.D. s presidential year ( ). Psychiatrist Jeremy Lazarus, M.D., who is president of the AMA, made integrated care a centerpiece of his presidential address last year (Psychiatric News, December 7, 2012). Psychiatric News has published numerous articles describing the growing consensus around integrated care. At APA s 2012 Institute on Psychiatric Services in New York, Jurgen Unützer, M.D., of the AIM center at the University of Washington described innovative Integrated Care Relies on Team Approach, Consultant Role for Psychiatrists The collaborative care model below, designed by the center for Advancing Integrated Mental Health Solutions, relies on a team approach that includes a care manager/behavioral health care provider who, along with the primary care physician, provides most direct patient care while the psychiatrist serves in a consultant role. In 5% to 7% of cases, patients will require direct care by the psychiatrist. Patient PCP Other Behavioral Health Clinicians Substance Treatment, Vocational Rehabilitation, CMHC, Other Community Resources Source: AIMS Center/Jurgen Unutzer, M.D. BHP/Care Manager New Roles Consulting Psychiatrist Core Program Additional Clinic Resources Outside Resources models of care that integrate psychiatric and general medical services and presented evidence that psychiatrists working in a consultative way with primary care can significantly improve mental health care for large populations of people in primary care, while also lowering overall health care costs. For instance, one of the largest randomized, controlled trials of this model is the IMPACT study conducted by Unützer and colleagues at the University of Washington from 1998 to In the original IMPACT study and numerous replications, patients receiving collaborative care were found to have less depression, less physical pain, better functioning, and a higher quality of life. There was also greater patient and provider satisfaction. Importantly, from a public-policy standpoint, IMPACT has lowered costs substantially for patients receiving the intervention through more efficient mental health treatment and lower use of inpatient care, pharmacy, and other outpatient services associated with comorbid medical conditions (Psychiatric News, November 2, 2012). Unutzer s work focused on the role of psychiatrists in overseeing depression care in primary care settings. The ad hoc Board work group found that additional research and study are needed in the care of individuals with psychiatric and substance use disorders in primary care settings and on integration of primary care physicians into public-sector mental health settings. Systems Are Evolving The report by the work group outlined a great number of recommendations regarding integrated care, including the following: APA should support the value of integrated general medical and psychiatric care for patients with psychiatric illness in all treatment settings. This support should be based on best evidence regarding optimal care for all patients and care that is patient-centered and consistent with goals of the Triple Aim. Particular attention should be paid to the distinct needs of patients of varying ages and in different care settings and, in particular, in the public sector. APA will need a comprehensive inventory of changes across the country and a rapid response capacity to assist in federal and state advocacy and support its membership. APA needs to produce a clear, simple set of statements for psychiatrists and their patients regarding integrated care; define the role of psychiatrists as see Integrated Care on page 19

20 15 Your Tech Questions to Be Answered by John Luo, M.D. APA s 2013 annual meeting is being held in San Francisco from May 18 to 22 just a few days away! Many consider the Northern California area to be the birthplace of the technology industry, which first started with the large number of silicon chip companies in the Santa Clara Valley. It is very appropriate then that at this year s annual meeting, a number of technology-focused workshops and courses are available to increase your knowledge and enhance your technical skills. I would like to highlight these activities to facilitate your ability to become a credentialed geek. (Check your program John Luo, M.D., is a physician informaticist at the UCLA Health System, where he has a significant role in the deployment of an enterprisewide electronic medical record system. He is an associate clinical professor of psychiatry in the UCLA Semel Institute for Neuroscience and Human Behavior and a past president of the American Association for Technology in Psychiatry. guide for locations.) Saturday, May 18 Symposium 1 Blogs, Tweets, Texts, and Friends: Professionalism and the Internet (9 a.m.-noon) This symposium is sponsored by the American Association of Directors of Psychiatric Residency Training. Presenters will cover liability and conflict of interest online, academic honesty, privacy/confidentiality, mandated reporting and safety on the Web, and the redefinition of the psychiatric frame with the multitudes of connections that the Internet provides. Symposium 9 Posttraumatic Stress Disorder Care in the U.S. Department of Veterans Affairs (9 a.m.-noon) Josef Ruzek, M.D., will review mobile apps in the delivery of psychotherapy for treatment of PTSD. I should have known that there is an app for that! American Association for Technology in Psychiatry ( org) (11 a.m.-1 p.m.) AATP, an APA allied organization, holds its annual meeting at APA as many of its members are presenters in the sessions listed in this article. The developers of Prezi, alternative presentation software to PowerPoint, will be on hand to discuss the future of presentations. In addition, the founder of Mevoked will review its software tool that helps determine the emotional state of users based on their browsing patterns and content consumed. Sunday, May 19 Workshop 39 Establishing Telepsychiatry and Telepsychotherapy Services for Nursing Home Residents: A Beacon Program (12:30 p.m.-2 p.m.) How to develop a telepsychiatry service to provide care in the nursing home is the focus of this workshop. The goals of the program are to use information technology to improve quality of population care and reduce cost of care. Workshop 45 What Are People Saying About You Online? Your E-Reputation and What You Can Do About It (12:30 p.m.-2 p.m.) What do patients say about you online? This workshop will help you learn what information is readily available on the Internet that impacts your privacy and professional reputation. The faculty will discuss ethics of certain behaviors as well as techniques to manage your e-reputation. Scientific and Clinical Reports 11 The Internet and Electronic Communication (2:30 p.m.-4 p.m.) This session will review suicide assessment using online social media and discuss how to implement an electronic health record in an outpatient setting. The impact of electronic health records as well as a Web-based shared decision-making tool will also be covered. Monday, May 20 Course 10 Exploring Technologies in Psychiatry (9 a.m.-noon) This perennial course covers the gamut of technology use in psychiatric practice. It will review everything and see Connections on page 23 More than just medical professional liability insurance... The risk manager is in... We have responded to over 40,000 issues on our risk management helpline since inception in This expertise helps you protect your practice and safeguard your reputation. - Charles D. Cash, JD, LLM Assistant Vice President, Risk Management More than 20,000 psychiatric claims handled Accredited by the ACCME Administrative and governmental billing defense coverage Coverage for forensic and telemedicine psychiatric services ECT/EST included at no additional charge Premium discounts - and much more! TheProgram@prms.com (800) ext. Come see us during the APA Annual Meeting! Visit or scan here for more details...

21 16 Psychiatric news May 3, 2013 Legal News Treating Illness in Justice System Comes at High Cost If more effort was expended on alternatives to the criminal justice system for people with serious mental illness, state budgets would take a far smaller hit. by Aaron Levin T he total costs for people with mental illness who are also involved with the criminal justice system are nearly double the costs for those without such involvement, according to a study of state mental health records in Connecticut. The justice-involved individuals each incurred total costs of $48,980 on average, compared with $24,728 per person for those not involved with the criminal justice system, said Jeffery Swanson, Ph.D., and colleagues in Psychiatric Services in Advance March 15. The researchers added up costs from the Connecticut Department of Mental Health and Addiction Services (DMHAS), Medicaid, the state judiciary, and the Department of Correction and Public Safety. Of the 25,133 adults served by the DMHAS in 2006 and 2007, 6,904 had been arrested and convicted of a crime or were in prison, on parole or probation, in a jail-diversion program, or spent time in a forensic psychiatry setting. Common diagnoses were schizophrenia (37 percent), bipolar disorder (63 percent), and a substance use disorder (65 percent). Patients with a psychiatric illness not involved in the criminal justice system had a different pattern of diagnoses. About 47 percent had schizophrenia, 54 percent had bipolar disorder, and 28 percent had a co-occurring substance use disorder. Such clinical differences may account for higher numbers of short-duration, Service Delivery Is Complex in Justice System acute hospital admissions, suggested Swanson and colleagues. Overall, individuals in the justice system accounted for mental health and substance abuse service costs of more than $215 million, with an average of $31,196, said the researchers. When an average of an additional $17,784 of other criminal justice costs were added, the total average cost per person was $48,980. The DMHAS covered about 49 percent of the costs for the justice-involved group and about 69 percent of the same costs for those outside the justice system. [F]orensic hospitalization was responsible for a large share of the difference in costs, said Swanson. Costs averaged $287,062 per person involved in the justice system, largely due to lengthy hospitalizations to restore competency or because defendants were found not guilty by reason of insanity. Among hospitalized patients, those outside the justice system had days paid for by the DMHAS, compared with 249 days for forensic patients. There are probably two reasons why forensic inpatients had such extended lengths of stay, suggested forensic psychiatrist James Reynolds, M.D., medical director at the state-run Northwest Missouri Psychiatric Rehabilitation Center in St. Joseph, Mo. As in other states, patients found incompetent to proceed to trial are often quite sick and thought disordered and take correspondingly longer to stabilize, said Reynolds, in an interview with Psychiatric News. Also, they can t just be released when they are less acutely ill, as in civilian settings. They usually must be kept as inpatients until ready for trial, and those who are permanently incompetent usually can t just be let go either. One potential area of cost saving might be the use of nonhospital To be competent to defend yourself in court, you can t just be good enough, you must really be pretty stable, James Reynolds, M.D., medical director of the Northwest Missouri Psychiatric Rehabilitation Center in St. Joseph, Mo., told Psychiatric News. Many defendants may refuse treatment for lengthy periods of time or only partially comply with treatment, thus lengthening their inpatient course. Missouri uses a strict conditional-release protocol to follow forensic outpatients, most of whom are law-abiding, free of substance abuse, and fully compliant with their medication and day-treatment programs, said Reynolds. It significantly affects the revolving door of civil mental health treatment that so tragically leads to patients eventually becoming involved in the criminal justice system, often to a victim s, not to mention their own, grief, he said. And it reflects our goal to treat them to the point of remission, or at least meaningful stability. We must find a way to respectfully and ethically ensure that the most severely ill individuals who are not mentally responsible for their conduct stay in meaningful treatment so they have the maximal chance of leading a life as free as possible in the community while not posing a risk of harm to themselves or others. crisis-intervention programs, said Erik Roskes, M.D., director of forensic services at Springfield Hospital Center in Sykesville, Md, in an interview. This could be used as a cost offset by avoiding use of expensive inpatient resources, [although] there is also a risk that forensic patients might be excluded from consideration due to their histories. One aspect of care for prisoners or arrestees was not included in the study, said Roskes. There is no mention of the general medical costs of these populations, which we know is very high, he said. In some cases, the medical problems relate directly to both the mental health and the criminal justice costs, as with traumatic brain injuries, for example. Roskes also noted that one group not cited in the research and that can be very costly to treat are people with comorbid cognitive/developmental disabilities. The study might serve as a model to analyze similar costs in other states, and its findings should help Connecticut health officials better plan, coordinate, and deliver services to these populations, concluded Swanson. PN An abstract of Costs of Criminal Justice Involvement Among Persons With Serious Mental Illness in Connecticut is posted at aspx?articleid= Resident Honors Department Chair Who Led Through Katrina This article is part of a series in the Residents Forum in which residents write about a mentor or psychiatrist who made a deep impression on them or influenced their career path. More information is available by contacting Catherine Brown at cbrown@psych.org. by Christopher Rodgman, M.D. Daniel Winstead, M.D., has been the chair and Heath Professor in Tulane Medical School s Department of Psychiatry and Behavioral Sciences for almost 26 years. At the time of his appointment as chair in July 1986, he was serving as associate chief of staff of education at the VA. Dr. Winstead first decided to pursue a career in academic psychiatry about halfway through his medical school career, thanks mostly to the influence of his mentors at the time, particularly Dr. Barry Blackwell, an expert in psychopharmacology and treatment issues regarding compliance/adherence and the subtle effects of medications that may resemble the effects of placebo; and Dr. Jack Lindy, the training director at the University of Cinicinnati, a heavily Christopher Rodgman, M.D., is chief resident in the Department of Psychiatry and Behavioral Sciences at Tulane University School of Medicine. He extends his appreciation to Ashlyn Van Pelt for transcribing the article, Melinda Hoehn for supplying the photograph, and Sarah Ryals for editing the article. psychoanalytically oriented program at the time. At Tulane, Dr. Winstead also credits the assistance of Donald Gallant, M.D., who introduced him to the Behavioral Sciences Research Group. Dr. Winstead also served in the U.S. Army. He was assigned to Nuremburg, Germany, and during that time he was able to organize peer learning groups to study for the board exams and review psychotherapy cases. As chair at Tulane, Dr. Winstead said that his greatest reward has been getting to watch people he has mentored move into successful academic careers and board positions. He also has appreciated being able to continue to publish and conduct his research projects. Dr. Winstead has enjoyed being active on a national level and continues to do so. He was a director of the American Board of Psychiatry and Neurology (ABPN) prior to being on the Residency Review Committee for Psychiatry of the Accreditation Council for Graduate Medical Education, and he served as president of a number of state and regional organizations, as well as national organizations like the Academy of Psychosomatic Medicine and the American College of Psychiatrists. Dr. Winstead said these were fun times for him, and that he is humbled by the opportunities he has had. Dr. Winstead s career has not been without hardship. During his tenure as chair at Tulane, Hurricane Katrina struck New Orleans, flooding much in its continued on facing page

22 17 PSYCH_IT Psychiatrists, Rate Your EHR! This column is produced by APA s Committee on Electronic Health Records, which is chaired by Steven Daviss, M.D. He can be reached at drdaviss@gmail. com. by Daniel Balog, M.D. Sometime this month, APA members will receive an invitation to complete an online survey on electronic health records (EHRs). The answers to these questions will provide a kind of Consumer Reports review from physicians who use EHR products, making it possible for physicians who do not yet use EHRs to turn to unbiased information from their peers not just information provided by vendors when making purchase decisions. The survey was developed by AmericanEHR Partners, an alliance between Cientis Technologies, a company that specializes in EHRs, and the American College of Physicians, AMA, American Academy of Family Physicians, and a dozen other provider organizations. The survey consists of general questions and questions specific to the practice of psychiatry. The psychiatric questions, which were developed by APA s Committee on Electronic Health Records, cover topics related to an EHR s ability to support DSM diagnoses and new coding requirements, ability to customize templates, ability to manage (separate) psychotherapy notes, Daniel Balog, M.D., is assistant chair of psychiatry at the Uniformed Services University School of Medicine and a member of the APA Committee on Electronic Health Records. and the ability to collaboratively create records with an integrated treatment team. While responses to the general questions will certainly provide useful information, responses to the specialtyspecific questions will provide information on functionality deemed critical to practicing psychiatrists. AmericanEHR Partners will combine APA survey responses with those from the other participating medical societies, covering a significant cross-section of medical professionals. To protect the integrity of this significant undertaking, participants will be cross-checked against society-member scrolls, but the identity of individual respondents will remain confidential. When you access the survey through the link provided to APA members in an , the psychiatry-specific questions will automatically be triggered. If you access the survey via an alternate association link (for example, the AMA), the data you provide will similarly trigger questions specific to AMA members When the survey period is over (most likely mid-may), APA will collect the psychiatry-specific results, publish them, and use them to focus on our specialty s unique EHR needs. To do this effectively, we need your input! As a small incentive, APA members completing the survey will be entered into a drawing for a free Apple ipad mini. Why should you take the time to participate? If you do not currently use an EHR system but may do so in the future, this survey gives you the perfect opportunity to voice your needs. If you are using an EHR system, then your experiences will provide the exact EHR-specific and specialty-specific data we are seeking. Not only will you be able to sound off on the good (and not so good) qualities of your EHR system, but also your impressions will be combined with others to inform discussions about EHR functionalities essential to psychiatric practice. APA members will have access to the survey data in a number of ways. To access real-time respondent informasee Psych_IT on page 24 Daniel Winstead, M.D., the chair of Tulane Medical School s Department of Psychiatry and Behavioral Sciences, poses with chief resident Christopher Rodgman, M.D. path including Dr. Winstead s home. In the wake of this tragedy, Tulane became synonymous with overcoming adversity. Due to Dr. Winstead s leadership, the Tulane Department of Psychiatry and Behavioral Sciences remolded itself and redirected its efforts to serving the community in new and innovative ways. Furthermore, Dr. Winstead pointed out that the department owes a great deal of thanks to Baylor and the University of Texas, which were very generous and supportive during this time by giving the department space to continue teaching Tulane medical students there. When asked what advice he has for other programs experiencing times of crisis, Dr. Winstead emphasized maintaining lines of communication in the department and focusing on the mission at hand. He noted that he and Candy Legeai, senior department administrator, have previously published in Academic Psychiatry about how they succeeded in these difficult tasks. Medical student teaching is job one, he said in an interview. Sometimes people don t necessarily like to hear that because they see themselves as only doing research, training residents, or treating patients. These are all importance facets of academics, but medical student teaching does come first, and that s why we deployed a group of our very best teachers to Houston to continue with the medical students. Dr. Winstead s leadership has continued to guide the program through difficult times. The mental health care system in Louisiana and indeed across the United States is currently facing a chaotic period of change with broad spending cuts, and Dr. Winstead s philosophy to overcome these challenges is to hunker down and hang on to what is important while continuing to do the best you can to weather the times. As far as advice for both students and faculty pursuing a career in academics, Dr. Winstead said that a solid footing in the science of psychiatry is important, followed by selecting an area of interest in which expertise can be developed and papers published. Academics is a marathon, not a sprint; there are going to be good times, and there are going to be rough times. He went on to say that psychiatrists who are faced with a slow time in terms of their academic productivity should use that time to broaden their horizons. Dr. Winstead used such times to take several courses from the School of Public Health at Tulane that have helped him in academia. As a great deal of Tulane s research programs were essentially wiped out during Katrina, other programs, in particular the academic writing class offered by Dr. L. Lee Tynes, have helped residents interested in careers in academia by showing them how to start small with book reviews, case reports, and literature reviews. Dr. Winstead emphasized how programs of this sort help individuals get off on the right foot in terms of developing publications and becoming familiar with scientific literature. Dr. Winstead also believes that for those who want to go into academics, research training is important. At Tulane, Roy Weiner, M.D., offers a two-year program that culminates in either a certificate or degree depending on the amount of coursework; another excellent avenue is the VA Mental Illness Research, Education, and Clinical Centers Fellowship that I am about to start with Thomas Newton, M.D., and Mark Kunik, M.D., in Houston. These types of fellowships and degrees were not available when Dr. Winstead was starting his academic career, and he therefore strongly encourages students to take advantage of these opportunities. After his time as chair comes to an end, Dr. Winstead plans to take a parttime sabbatical in New Orleans while continuing to work with the ABPN assisting with comparing PRITE and Child PRITE scores and the scores on the new computerized board exam. As past president of the American College of Psychiatrists, he noted he is in an excellent position to help facilitate that work. Dr. Winstead also hopes to work, with the assistance of Laura Roberts, M.D., to survey former Laughlin Fellows and PRITE Fellows of the American College of Psychiatrists concerning the outcome of their leadership development activities. PN

23 18 Psychiatric news May 3, 2013 annual meeting No Shortage of Fun for Kids And Those Who Once Were San Francisco s kid-friendly side offers lots of opportunities to blend fun with a little education as well. by Aaron Levin S an Francisco has lots of places to keep the kids happy while mom or dad is in town for APA s annual meeting in May. Easiest to reach is the Children s Creativity Museum, located right above the meeting venue on the roof of Moscone South. The museum (formerly known as Zeum) provides hands-on experiences in animation, sound, and video production, live performance, and visual arts. Visitors combine their imaginations with the museum s art and technology tools to create clay animation, make music videos, compose a soundtrack, or experiment with digital art. Plus the kids can take home their completed projects on a DVD. Over on Pier 39 at the Embarcadero, is the San Francisco Carousel. Handcrafted in Italy, it is intricately hand painted and depicts famous San Francisco landmarks, including the Golden Gate Bridge, Coit Tower, Chinatown, Lombard Street, Alcatraz, and the popular California sea lions that hang around at the end of the pier. Kids can ride on one of the carousel s 32 animals, including sea dragons, sea lions, dolphins, panda bears, and, of course, horses. Throughout the ride, patrons hear traditional organ music and watch the passing scene on Pier 39 s bustling promenade. Other carousels in the city can be found in Golden Gate Park, at the San Francisco Zoo, and atop the roof of Moscone South. Also on Pier 39, San Francisco s Aquarium of the Bay offers an insight into that watery environment without having to get wet. Visitors begin with an introduction to the ecosystems that support marine life in San Francisco Bay, then view displays of more than 1,000 aquatic animals. A moving walkway takes guests through two clear tunnels, 300 feet long, surrounded by 700,000 gallons of filtered bay water holding more than 20,000 bay-dwelling creatures. Other tunnels reveal the near-shore habitat with giant schools of anchovies and colorful sea stars and deeper-water creatures like bat rays, rare angel sharks, and unusual eight-foot-long, seven-gill sharks. The final exhibit recreates the California coast. Visitors encounter a series of pools where they can touch live bat rays, leopard sharks, and tide-pool marine life. A Behind the Scenes tour of the aquarium is available for an additional fee. At the Randall Museum in Corona Heights Park near the city s center, visitors can explore nature and the environment. One exhibition, Wild in the City, features wildlife including coyotes, raccoons, and skunks with whom humans share the urban environment. The museum also has a permanent exhibit about earthquakes, San Francisco s emblematic municipal event. A seismograph in the exhibit is connected to a seismometer in the basement that registers earthquakes around the world in real time. Visitors can learn about plate tectonics while playing with the museum s hands-on replica of the Hayward Fault. In Golden Gate Park, the Children s Playground dates from 1887, when providing a space solely for youth recreation was a groundbreaking innovation. San Franciscans call it the nation s first public playground. The design reflects the transition of San Francisco s natural landscape descending from hills to shore to sea. Children can climb wave walls, Product Theaters Offered on Variety of Topics explore sea caves, clamber over seaside animal sculptures, slide down a hillside, and ignore their parents in a tree-house village. New Exploratorium to Open One major attraction for kids will be reopening in a brand new location in April, just in time for the annual meeting. The Exploratorium is moving from its old location in the Palace of Fine Arts to Pier 15 on the Embarcadero. The new site triples the space for this museum see Kids on facing page Product theaters will again be held this year during the annual meeting. These promotional programs are being held as an extension of the Exhibit Hall. They feature promotional programs supported by exhibitors. CME credit is not provided for these sessions. The 60-minute sessions will be held in Exhibit Hall A-C on the Exhibit Level in the Moscone Convention Center. Sessions will run from Sunday, May 19, to Tuesday, May 21, with three sessions each day at 11 a.m. and 1 p.m. Boxed lunches and beverages are provided by APA for the programs. Topics may include treatment management, disease updates, and issues of interest to the supporting company. Supporters of the sessions include Takeda Pharmaceuticals America Inc., Lundbeck Inc., Sunovion Pharmaceuticals Inc., Genentech Inc., Genomind, AstraZeneca, and Otsuka America Pharmaceuticals Inc. Look for signs announcing the presenters and topics in the convention center and outside the product theater. All product theaters will be held in Booth 2326 in Exhibit Hall A-C, in the Moscone Convention Center. Seating is limited to 250 on a first-come basis. Sunday, May a.m.-noon Sponsored by Takeda Pharmaceuticals America Inc. and Lundbeck Inc. Depression: Deeper Evaluation of Symptoms and Neurobiology Presenter: Pierre Blier, M.D., Ph.D., director of the Mood Disorders Research Unit University of Ottawa Institute of Mental Health Research and professor in the departments of Psychiatry and Cellular and Molecular Medicine, University of Ottawa 1 p.m.-2 p.m. Sponsored by Sunovion Pharmaceuticals Inc. Challenges and Opportunities in Schizophrenia Treatment Presenter: Stephen M. Stahl, M.D., Ph.D., adjunct professor of psychiatry, University of California San Diego School of Medicine; honorary visiting senior fellow, University of Cambridge, United Kingdom; editor-in-chief, CNS Spectrums; director of Psychopharmacology Services, California Department of State Hospitals Monday, May a.m. -Noon Sponsored by Genentech Inc. Novel Mechanisms and Disease Awareness (NMDA) in Schizophrenia Presenter: Peter J. Weiden, M.D., professor of psychiatry and director, Department of Psychiatry Psychosis Treatment Program, University of Illinois at Chicago Nito/Shutterstock The two-story carousel at San Francisco s Pier 39 is a perfect stopping point for kids. 1 p.m.-2 p.m. Supported by Genomind The Link Between Mental and Physical Health: Using Genetics to Treat the Whole Patient Presenter: Jay Lombard, D.O., cofounder, chief scientific officer, and medical director for Genomind Tuesday, May a.m.-noon Supported by AstraZeneca An Approach to Treating Acute Depressive Episodes of Bipolar Disorder Presenter: Richard Jackson, M.D., associate clinical professor of psychiatry, Wayne State University School of Medicine; assistant clinical adjunct professor of psychiatry, University of Michigan School of Medicine 1 p.m.-2 p.m. Sponsored by Otsuka America Pharmaceutical Inc. and Lundbeck Inc. Help Protect Your Patients From Relapse: A New Treatment Option for Schizophrenia Presenter: Andrew J. Cutler, M.D., founder, Florida Clinical Research Center, and assistant professor of psychiatry, the University of Florida

24 Annual Meeting 19 Minority, Underrepresented Groups Share Concerns Through Caucuses P sychiatrists who identify with any of APA s recognized minority and underrepresented (M/UR) groups are urged to join that group s caucus and attend its meeting at APA s 2013 annual meeting in San Francisco later this month. The minority and underrepresented group caucuses were established to provide a networking opportunity and foster communication among members who share a special interest. There are caucuses for the following groups: American Indian/Alaska Native/ Native Hawaiians; Asian Americans; blacks; Hispanics; lesbians, gays, and bisexuals; international medical graduates; and women. Participation in a caucus is a pathway to the following: Exploring concerns about professional growth and advancement. Identifying, supporting, and electing top-notch M/URs for leadership posts. Networking with members with shared backgrounds. Advocating for minority patient populations. Talking about key issues facing APA. Initiating mentoring relationships. Bringing concerns to APA leadership. Assuming leadership roles in APA. PN To join a caucus, go to psychiatry.org and click on Join & Participate, and then My Account. Log into your account, click on Member Profile, go to question 3Fa, and select the appropriate caucus(es). More information is available from Alison Bondurant at abondurant@ psych.org. APA Minority Caucuses: Meet With Like-Minded Colleagues Sunday, May 19 2 p.m.-3:30 p.m. Caucus of Hispanic Psychiatrists Sierra Conference Suite F, 5th Floor, San Francisco Marriott Marquis 3 p.m.-4:30 p.m. Caucus of Gay, Lesbian, and Bisexual Psychiatrists and Association of Gay and Lesbian Psychiatrists (Joint Meeting) Howard Room, 5th floor, Intercontinental San Francisco Monday, May 20 4 p.m.-5 p.m. Caucus of International Medical Graduate Psychiatrists Laurel Room Upper B2 Level, San Francisco Marriott Marquis 6:45 p.m.-7:45 p.m. Caucus of Black Psychiatrists Golden Gate Hall, Salon C3, Level B2, San Francisco Marriott Marquis 6:45 p.m.-8 p.m. Caucus of Asian-American Psychiatrists Pacific Suite E, 4th Floor, San Francisco Marriott Marquis 6:45 p.m.-8:30 p.m. Caucus of American Indian, Alaska Native, and Native Hawaiian Psychiatrists Laurel Room Upper B2 Level, San Francisco Marriott Marquis Tuesday, May 21 5:30 p.m.-7:30 p.m. Caucus of Women Psychiatrists and the Association of Women Psychiatrists (Joint Meeting) Pacific Suite 1, 4th Floor, San Francisco Marriott Marquis Integrated Care continued from page 14 team leaders and consultants; state how their role in integrated care will benefit patients; and clarify psychiatry s role vis-à-vis other physicians, allied health practitioners, and other mental health clinicians. The report emphasizes that psychiatrists, because of their medical expertise and extensive training with seriously ill psychiatric and medical patients, have distinctive expertise to integrate this care, working closely with primary care, specialty physicians, and nonphysician mental health clinicians. This expertise, the report notes, is borne out by the research evidence. In an interview with Psychiatric News, Summergrad emphasized that while the general movement in health systems is toward greater collaboration between specialty care and primary care, the sheer scope of health system change makes it difficult to know exactly how systems will evolve in different regions of the country. Also, there are many other unknowns that will require ongoing vigilance by APA and its district branches. What is especially unclear is how care will be paid for in the future. Will it be through large integrated systems? Will fee-for-service reimbursement for specialists be replaced by global or bundled payment models? We recommended integrated financing models to allow the full and equitable reimbursement for our patients and for psychiatric physicians. Regardless of which models are adopted, the current efforts to secure parity need to continue, he said. I want to emphasize that we don t presume to think traditional forms of psychiatric practice will all change let alone disappear but it is clear that in many settings closer integration between general medical care and psychiatry in primary care or in specialty mental health settings will be very important. PN APA has established a Work Group on Integrated Care, chaired by Lori Raney, M.D., medical director of the Axis Healthcare System in Durango, Colo. The Integrated Care Track at this year s annual meeting will feature lectures, symposia, workshops, and other presentations. The schedule is posted at newsarticle.aspx?articleid= APA is also sponsoring an all-day program, Clinical Updates in Primary Care Psychiatry: For Primary Care and Mental Health Providers, on Friday, May 17, from 7:45 a.m. to 5 p.m., in the Moscone Convention Center. The registration fee is $299. More information is available by calling (888) Kids continued from facing page of science, art, and human perception. For instance, the Bay Observatory Gallery erases boundaries between indoor and outdoor at the dynamic intersection where the built environment and nature meet. In the Exploratorium s Central Gallery, visitors investigate light and sound and how humans perceive them. The San Francisco Cable Car Barn, Powerhouse, and Museum on Nob Hill gives visitors a peek into the history and workings of the city s iconic i more information symbol. Three antique cable cars are on display, including the very first, placed into service in Visitors can view the cable-winding machinery that operates the system, as well as the path of the cable entering the building and leaving underneath the street in the sheave room. The best way to get to the Powerhouse is (how else?) by cable car. Of course, there s always the zoo. The San Francisco Zoo is located next to the Pacific Ocean and houses 250 species ranging from insects to giraffes. Five botanical exhibits round out the collection. PN Exploratorium: 698 Embarcadero (Pier 15), (415) , Children s Playground (sometimes called the Koret Children s Center) 320 Bowling Green Drive, (415) , Aquarium of the Bay: Next to Pier 39 at the Embarcadero and Beach Street, Fisherman s Wharf, (888) SEA-DIVE,, Children s Creativity Museum: 221 Fourth Street, (415) , San Francisco Cable Car Barn, Powerhouse, and Museum: 1201 Mason Street, (415) , Randall Museum: 199 Museum Way (near the intersection of Castro and States streets), (415) , San Francisco Zoo: 1 Zoo Road, (415) , Also see:

25 Dr. Nora Volkow and the The National Institute on Drug Abuse The Addiction Performance Project Featuring: A dramatic reading of Long Day s Journey into Night by professional, award-winning actors Emmy Award winning actress Kate Burton, whose television credits include Dr. Ellis Grey on Grey s Anatomy and Vice President Sally Langston on Scandal* An expert panel featuring Nora D. Volkow, M.D., Steven L. Batki, M.D., and Roger D. Weiss, M.D. A lively audience discussion invite you to attend at the 2013 American Psychiatric Association Annual Meeting Sunday, May 19 2:00 p.m. 4:00 p.m. Moscone Convention Center, Room 130/131 North Building, Exhibit Level For more information, visit: *Actors subject to change

26 Clinical & Research News 21 Serotonin Transporter Binding Low In Suicide Attempters Brain imaging might eventually be used to predict suicide risk, following a finding that low serotonin transporter binding is associated with suicide attempts. by Joan Arehart-Treichel T he brain biology of depressed individuals who have attempted suicide seems to differ from that of depressed individuals who have not attempted suicide. So reported Jeffrey Miller, M.D., an assistant professor of clinical psychiatry at Columbia University, and colleagues March 4 in Biological Psychiatry. Miller and his team conducted a PET brain imaging study of 51 subjects with major depressive disorder 15 of whom had also attempted suicide as well as of 32 healthy control subjects. They found that the depressed suicide attempters had significantly lower binding of the serotonin transporter in the midbrain region than did depressed subjects who had not made a suicide attempt and than did healthy control subjects. Thus, Low midbrain serotonin transporter binding appears to be related to the pathophysiology of suicidal behavior rather than of major depressive disorder, Miller and his colleagues concluded. This finding is important, Fabrice Jollant, M.D., Ph.D., an assistant professor of psychiatry at McGill University and an expert on suicide imaging, told Psychiatric News. The finding is in line with numerous biological investigations conducted over the past 35 years using biochemical measures in the cerebrospinal fluid, cellular and molecular explorations in postmortem studies, neuropsychology, or structural and functional neuroimaging. For instance, low serotonin levels in the cerebrospinal fluid have been linked with suicide behavior in prior research studies. It would also be helpful if the finding could be used to identify individuals prone to suicide before they act on it, Jollant indicated, as clinicians clearly need Serotonin transporter binding in the midbrain, shown here, is linked with risk of suicide attempts. to improve their predictive ability. The problem, however, is that while the differences in serotonin transporter binding between the suicide attempters and nonattempters or between the suicide attempters and controls were statistically significant, there were large overlaps, he said. So I think that there are a lot of uncertainties regarding the use CLIPAREA/Custom media/shutterstock of [serotonin binding levels] in the near future to predict suicide risk. What is now needed, he pointed out, is a longitudinal study with a sufficient number of participants and a sufficient duration of follow-up to determine whether serotonin transporter binding levels can truly help predict who is going to attempt suicide. And Miller said that he and his colleagues are already conducting such an investigation. We will be following the subjects who are already enrolled in this study, conducting detailed psychological interviews three months, one year, and two years after PET scanning. At these time points, in addition to acquiring other clinical data, we will assess suicidal behavior and ideation in the intervening period since the last interview. These data will allow us to examine whether serotonin transporter levels as assessed by PET imaging play a role in predicting future suicide attempts over time. The study was funded by the National Institute of Mental Health. PN An abstract of Positive Emission Tomography Quantification of Serotonin Transporter in Suicide Attempters With Major Depressive Disorder is posted at www. biologicalpsychiatryjournal.com/article/ S (13) /abstract. Diagnosis and Management of Lewy Body Disease by Myron weiner, M.D. The sudden onset of visual hallucinations in elders should arouse suspicion about the presence of Lewy body disease, as should the development of delirium in elderly medical or surgical inpatients. The diagnosis is important because these individuals should not be treated with antipsychotics other than quetiapine (clozapine has been suggested, but is, in my opinion, too toxic for elders). Additional treatment-related features of Lewy body disease are that the visual hallucinations respond well to the anticholinesterases used to treat Alzheimer s disease and are aggravated by anticholinergic agents and the dopamine agonists used to treat Parkinson s disease. Lewy body disease (also, and perhaps unfortunately, termed dementia with Lewy bodies) is probably the second most common neurodegenerative disease that causes severe cognitive i mpa i r ment i n elders. About 20 percent of cases diagnosed clinically as Alzheimer s disease also have abundant neocortical Lewy bodies, but pure Lewy body disease is rare. Lewy body disease is characterized pathologically by the presence of intraneuronal synuclein-containing Lewy bodies throughout the cerebral cortex. It belongs to the group of diseases now known as synucleinopathies, the most common of which is Parkinson s disease. The basic pathological difference between Lewy body disease and Myron Weiner, M.D., is a clinical professor of psychiatry and neurology and neurotherapeutics at the University of Texas Southwestern Medical Center. He is also the author of Clinical Manual of Alzheimer Disease and Other Dementias, which APA members can order at a discount from American Psychiatric Publishing at SearchDetail.aspx?ItemId= Parkinson s disease is the location of Lewy bodies; if densely present only in the substantia nigra, the clinical syndrome is Parkinson s disease. The distinction between Lewy body disease and Parkinson s disease with dementia is arbitrary and is based on whether cognitive or motor symptoms begin first. At a clinical level, the distinction between Lewy body disease and Alzheimer s disease is frequently unclear. Most Lewy body cases co-occur with Alzheimer s disease, and these cases are often called the Lewy body variant of Alzheimer s disease. The visual hallucinations of Lewy body disease are quite characteristic. They are well-formed images of adults or children whose identity is not known and who do not speak. They are often seen to enter or exit a room, and the patient has no explanation of why they are there. The hallucinations are at times terrifying, but more commonly the patient is just puzzled. They usually occur with clear sensorium, but vague hallucinations may occur on going to or awakening from sleep. Patients frequently report that they cannot distinguish between events that occur in dreams and events that occur in reality. Most important in differentiating Lewy body disease from lateonset schizophrenia or other psychotic disorders is that there is no delusional elaboration of the visual hallucinations. If given an antipsychotic agent, these individuals are prone to developing acute extrapyramidal syndromes and may develop neuroleptic malignant syndrome. Some persons with Lewy body disease present with a history identical to Alzheimer s disease. Additional factors concerning persons with Lewy body disease include the presence or history of sleepwalking and REM sleep behavior disorder. Unlike Alzheimer s disease, in which most patients lack insight into their cognitive difficulty, persons with Lewy body disease tend to be aware of their deficits and can often speak of see From the Experts on page 29

27 22 Psychiatric news May 3, 2013 Clinical & Research News Infants Eyes May Reveal Clue to Autism Risk Eye movements and visual attention are measurably delayed in infants who are later diagnosed with ASD. Screening of Postpartum Women Shows High Rates of Depression Researchers say thorough screening of postpartum women will identify women seriously at risk for mental health disorders and save lives. by Leslie Sinclair D epression is a frequent complication of childbearing, but how useful is screening new mothers for depression? And what steps should be taken on the basis of such screening? Those are questions Katherine Wisner, M.D., and her colleagues sought to answer when they recently evaluated 10,000 mothers at an urban obstetrical hospital using the Edinburgh Postnatal Depression Scale (EPDS). In their study, published March 13 in JAMA Psychiatry, the researchers said that this is the largest American population to undergo screening with the EPDS. Wisner is director of the Northwestern University Asher Center for the Study and Treatment of Depressive Disorders, as well as the Norman and Helen Asher Professor of Psychiatry and Behavioral Sciences and a professor of obstetrics and gynecology at Northwestern University Feinberg School of Medicine in Chicago. Wisner was formerly a professor of psychiatry, obstetrics, gynecology, and reproductive sciences and epidemiology at the University of Pittsburgh School of Medicine and performed the research in this study there. Of the postpartum women Wisner and her colleagues screened, 14 percent (1,396 mothers) had positive findings. Screen-positive women were more likely to be younger, African American, publicly insured, single, and less well educated. More of the episodes began postpartum (40.1 percent), followed by those that began during pregnancy (33.4 percent) and before pregnancy (26.5 percent). In this population, 19.3 percent had thoughts about harming themselves; mothers with the highest intensity of self-harm ideation were identified with an EPDS score of 10 or higher. The most common primary diagnoses were unipolar depressive disorders (68.5 percent), and about two-thirds had comorbid anxiety disorders. The researchers noted that a striking number, 22.6 percent, had bipolar disorders and called for the development of strategies to differentiate women by Leslie Sinclair A bnormal oculomotor functioning in infants may portend a diagnosis of autism spectrum disorder (ASD). Researchers participating in the Infant Brain Imaging Study (IBIS) reported in the March 20 AJP in Advance that sevenmonth-old infants who are eventually diagnosed with ASD take a split second longer to shift their gaze during a task measuring eye movement and visual attention than do typically developing infants of the same age. The gaze delay lasts only 25 to 50 milliseconds on average, too brief to be detected in normal social interactions with an infant. But lead author Jed Elison, Ph.D., of the University of North Carolina at Chapel Hill and the California Institute of Technology and colleagues report that the delay is measurable and could possibly be accounted for by differences in the structure and organization of actively developing neurological circuits of a child s brain. Their data were collected from 97 infants, of whom 16 were considered to have high familial ASD risk due to having an older sibling already diagnosed with ASD and who were later diagnosed as having ASD themselves. Another 40 were at high familial risk but did not later meet ASD criteria, and 41 were low-risk infants. All of the infants were enrolled at approximately 6 months of age and underwent a comprehensive behavioral assessment and brain imaging protocol at the ages of 6, 12, and 24 months. The data used in the analysis included behavioral, imaging, and eye-tracking data from the initial sixmonth visit and clinical assessment data from the 24-month visit. Imaging methods assessed radial diffusivity (an index of white matter organization) in fiber tracts that included corticospinal pathways and the splenium and genu of the corpus callosum. The children were assessed at the University of North Carolina at Chapel Hill and Children s Hospital of Philadelphia. The study was conducted in the context of an ongoing Autism Center of Excellence Network study, which was prospectively investigating longitudinal brain and behavioral trajectories in high-familial-risk infant siblings of children diagnosed with ASD and low-risk comparison infants. Visual orienting delays were longer in 7-month-old infants who later showed ASD symptoms, compared with both high-risk negative infants and low-risk infants. The research also indicated that the size of the splenium was associated Suicide accounts for about 20 percent of postpartum deaths. Childbearing is an opportune time for screening and intervention for maternal depression, because of the increased contact with health care professionals. with bipolar from unipolar disorders. The overwhelming majority of those with unipolar disorders were identified as having major depressive disorder, a finding the researchers said was consistent with other epidemiological studies. In the U.S., the vast majority of postpartum women with depression are not identified or treated even though see Depression on page 28 Infants were shown images on a screen while their eye movements were recorded and measured. NatesPics/Shutterstock.com with the speed with which the low-risk infants were able to shift their gaze, but in infants later found to have ASD there was no correlation between splenium size and speed of gaze shift. The researchers theorized that the differences in gaze shifting between the two groups may not be due directly to differences in the splenium between the groups, but to differences in the brain circuit that connects the splenium to visual areas of the brain. Could oculomotor assessment of infants enhance early identification of those who develop ASD? Elison and his colleagues hope for more than that: The present behavioral findings not only complement and extend recent data suggesting early functional and structural brain abnormalities in infants who go on to develop ASD, they said, they also have the potential to enhance early identification of individuals with ASD and to inform targeted interventions developed for the ASD prodrome. They noted that one recent study successfully altered visual orienting performance in 11-month-old infants using several gazecontingent attention training procedures administered during five visits over 15 days. Additional research is needed to determine the long-term effects of modifying visual orienting patterns in infancy, specifically in relation to how training attention at specific time intervals during infancy might alter social-cognitive development, they concluded. The research is part of the ongoing Infant Brain Imaging Study, which is supported through the National Institute of Child Health and Development s Autism Centers of Excellence Program, Autism Speaks, and the Simons Foundation. PN An abstract of White Matter Microstructure and Atypical Visual Orienting in 7-Month-Olds at Risk for Autism is posted at articleed= Information about the Infant Brain Imaging Study (IBIS) Network consortium is posted at network.org/. Noah Sasson, Ph.D., University of Texas at Dallas.

28 23 by Leslie Sinclair FDA Approves Monthly Aripiprazole Injection For Schizophrenia Otsuka Pharmaceutical and Lundbeck announced February 28 the FDA approval of Abilify Maintena, an extended-release injectable suspension of aripiprazole, as an intramuscular depot formulation indicated for the treatment of schizophrenia. The product is the first dopamine D2 partial agonist approved as a once-monthly injection. Efficacy was demonstrated in a 52-week, placebocontrolled, double-blind, randomizedwithdrawal, phase 3 maintenance trial in patients with schizophrenia. The time to relapse was the primary endpoint. In a press release announcing the approval, Otsuka and Lundbeck noted that elderly patients with dementiarelated psychosis treated with antipsychotic drugs are at increased risk of death, and this product is not approved for the treatment of patients with dementia-related psychosis. in the directions for use on the labels of these products are no longer necessary to ensure that they are used safely and effectively for smoking cessation. The label changes that the FDA is allowing reflect that although any nicotine-containing product is potentially addictive, decades of research and use have shown that nicotine replacement therapy products sold over the counter do not appear to have significant potential for abuse or dependence. The changes being recommended include a removal of the warning that consumers should not use a nicotine replacement therapy product if they are still smoking, chewing tobacco, or using snuff or any other product that contains nicotine, including another nicotine replacement therapy product. The agency heard from several public-health groups that the labeling for over-the-counter nicotine replacement products may stop consumers who are trying to quit smoking from using them, said FDA Commissioner Margaret Hamburg, M.D. FDA hopes the recommended changes will allow more people to use these products effectively for smoking cessation and that tobacco dependence will decline in this country. The agency cautioned that labeling changes may not occur immediately and that product users should still read the packaging and labeling of any nicotine replacement therapy product they select and consult with their health care professional if they have questions. The FDA s update on labeling changes for nicotine replacement therapy products is posted at ForConsumers/ConsumerUpdates/ ucm htm. Lundbeck Announces Positive Results From Study of Drug for MDD On April 8, Lundbeck announced positive results for the REVIVE study, a 12-week double-blind randomized study of Brintellix (vortioxetine) versus agomelatine in adults with major depressive disorder (MDD) who changed antidepressant treatment after an inadequate response to SSRI or SNRI treatment. The study s objective was to compare the efficacy and tolerability of flexible-dose treatment with Brintellix (10-20mg/day) with those of agomelatine (25-50 mg/day). The study was conducted in Europe, and agomelatine was chosen as a comparator because of its different mode of action from conventional SSRI/SNRI therapies. The primary efficacy endpoint was change from baseline to week 8 in the Montgomery Asberg Depression Scale (MADRS) total score. Secondary endpoints included assessments of anxiety symptoms, global clinical judgment, and overall functioning. On the primary efficacy endpoint, Brintellix was statistically significantly superior to agomelatine by 2.2 MADRS points. Significant differences in favor of Brintellix were also found for all other measures from week 4 onwards. Brintellix was well tolerated, with fewer patient withdrawals in the Brintellix group vs. agomelatine. Lundbeck said it plans to present further efficacy and safety data from its clinical program at the APA annual meeting in San Francisco this month. PN BioLineRx Antipsychotic Misses Endpoint BioLineRx announced March 20 that results from a preplanned interim analysis of the phase 2/3 CLAR- ITY trial of BL-1020, an orally available GABA-enhanced antipsychotic for the treatment of schizophrenia, indicate that the trial would not meet the prespecified primary efficacy endpoint. After conferring with the study s independent Data Monitoring Committee, the company has decided to discontinue the CLAR- ITY study. No additional patients will be enrolled. The interim analysis included data on 230 subjects, of whom 168 were evaluable for analysis on the primary (six-week) cognitive endpoint. The analysis indicated no efficacy of BL-1020 when compared with risperidone relative to the cognitive primary and secondary (12- week and 24-week) endpoints. The company said it intends to perform a complete analysis of the unblinded study data on all patients enrolled to date to ascertain whether there may be future potential for the product. FDA Allows Changes To Nicotine Replacement Therapy Product Labels The Food and Drug Administration (FDA) announced April 1 that it has reviewed research on the safety of nicotine replacement therapy products sold over the counter and has decided that some warnings and limitations specified Connections continued from page 15 anything, from hardware devices to software services, social media to encryption technology, and maintaining your privacy in the sea of Internet information. Symposium 59 Comorbidity, Mechanism of Treatment Resistance, and Novel Treatment Development for Late-Life Depression (9 a.m.-noon) Sarah Morimoto, Psy.D., will discuss use of computerized cognitive remediation in geriatric depression. Who knew that your grandmother s mood could really benefit from using a Gameboy! Workshop 80 Social Media and the Internet: New Challenges to Boundaries in Psychiatry (1:30 p.m.-3 p.m.) Paul Appelbaum, M.D., will discuss the ramifications of friending your patients, as well as how texting and tweeting impact patient care. Its singular focus on social media is sure to draw a crowd. Tuesday, May 21 Course 36 Brain Stimulation in Psychiatry (9 a.m.-noon) This course reviews various brain stimulation techniques and their treatment implications. Attendees will get a review of neuroanatomy as well as principles of electrical neuromodulation. Topics include vagus nerve stimulation therapy, transcranial magnetic stimulation, and deep brain stimulation. Symposium 91 Getting Started with Electronic Health Records in your Practice (9 a.m. noon) The APA Committee on Electronic Health Records will review the major issues regarding EHRs. Privacy, data sharing, usability, benefits, and meaningful use are just a few of the topics this group will discuss. More importantly, they will teach you how to select and implement the EHR that you choose. Lecture 26 Are Digital Technologies Impacting on Wellness of the Young Mind? (11 a.m.-12:30 p.m.) The child psychiatrists at the annual meeting should definitely attend this lecture. The American Academy of Pediatrics recommends less than two hours a day of media exposure. Baroness Susan Greenfield, D.Phil., M.A., will hopefully answer the question whether your child should have an ipad! Workshop 119 Improving Clinical Efficiency With Do-It-Yourself Intranet Web Browser Applications (3:30 p.m.-5 p.m.) David Gotlib, M.D., has demonstrated how to create an Intranet-based electronic whiteboard for tracking patients in the emergency department dl.dropboxusercontent.com/u/49189/ewhiteboard/index.html, described in an article in Psychiatric Services. This workshop will help even technology novices develop their own system. Wednesday, May 22 Symposium 129 First Steps in Helping Patients With First-Episode Psychosis (9 a.m.-noon) The use of mobile devices to increase care delivery will be covered by Trishan Panch, M.B.B.S., M.P.H. Workshop 153 E-Psychiatry: How Innovative Web Sites Reach Diverse Populations (1:30 p.m.-3 p.m.) Strategies on how to create an effective Web site will be covered. In particular, diverse populations often have specific needs that make access and finding sites and a challenge. The workshop presenters have solved this mystery. While the release of DSM-5 is at the forefront of the meeting, there are a significant number of excellent sessions on information technology. It would be a shame to be next door to Silicon Valley and not partake in these technology offerings. I hope to see you there! PN

29 24 Psychiatric news may 3, 2013 Clinical & Research News Could DNA Methylation Affect Suicide Risk? Genomewide DNA methylation changes in the hippocampus affect risk of suicide, especially in genes tied to learning, memory, and behavior. by Aaron Levin G enomewide DNA methylation differences in gene promoter regions in the hippocampus reveal some significant associations with suicide risk, according to researchers at McGill University in Montreal. [O]ur findings suggest that such mechanisms may, in individuals with particular behavioral, molecular, and cellular predispositions, increase susceptibility to suicide, said Gustavo Turecki, Ph.D., a professor of psychiatry and human genetics and director of the McGill Group for Suicide Studies, and colleagues in AJP in Advance online March 20. We think that epigenetic changes occurring early in life may influence how personality traits develop, said Turecki, in an interview with Psychiatric News. The epigenetic regulation of these processes in the brain may be altered in suicide completers, leading to the dysregulation of cognitive processes. The researchers studied postmortem samples provided by the Quebec Suicide Brain Bank from 46 men who died by Psych_IT continued from page 17 tion, members can use their free AmericanEHR Partners account at psychiatry. org/ehrsurvey, created during the survey, to view results that are filtered and sorted. Members seeking top 10 results, sorted by practice size, can view results in categories to include Satisfaction, Usability, Prescribing, Workflow Management, Ordering, Population Management, Implementation, Training, Support, Interfaces, Billing, and Purchase Experience. Finally, once the active survey period is over, APA s Committee on Electronic Health Records will make the psychiatry-specific results available to members as well. AmericanEHR Partners has created an online clinician community that focuses on the use of health information technology in the delivery of medical care. AmericanEHR Partners organizes suicide and 16 controls who died suddenly by other means and did not have a psychiatric illness. They examined DNA methylation in promoter regions of 23,551 genes in the hippocampus. Methylation is associated with regulation of gene expression. We used a genomewide approach rather than a candidate-gene approach, said Turecki. A genomewide approach interrogates all genes in the genome rather than a single or group of genes. The researchers found significant differences at 366 locations between the suicide and control cohorts. Of those, 273 probes reflected hypermethylation and 93 were hypomethylated in the hippocampus. They initially investigated the hippocampus because it is involved in stress response and is highly plastic, Turecki explained. We are now in the process of looking at other important brain regions. Mean gene expression and mean methylation levels were inversely correlated in the study sample. The appearance of variable methylation across the genome suggested that epigenetic changes in psychiatric disorders may not be limited to a short DNA Methylation and Gene Expression Vary Inversely Percentage of DNA methylation of NR2E1 gene promoter is higher in suicide completers than in controls (left) and varies inversely with gene expression (right). % of Methylation information and facilitates optimal decision making through education, social media, and peer-contributed data. It also provides physicians, agencies, and vendors with tools to identify, implement, and effectively use EHRs and other health care technologies. Once the survey results are in, psychiatrists and organizational leaders will have additional information to inform EHR purchase decisions. Similarly, those already using EHRs will have another platform in which to communicate concerns specific to psychiatry. If APA participation is robust, then we can potentially add thousands of voices to influence the development of EHRs and other technologies that are increasingly at the center of how we communicate, access, interpret, and comply. PN More information about AmericanEHR Partners can be accessed at americanehr.com/home.aspx Suicide completer NR2E1 Relative Expression Comparison subject Source: Benoit Labonte, Gustavo Turecki, et al., AJP in Advance, March 20, list of specific gene candidates but may affect multiple functional gene networks in multiple chromosomal regions, the researchers concluded. This is an interesting study and is carefully done, noted Lisa Monteggia, Ph.D., an associate professor of psychiatry at the University of Texas Southwestern Medical School in Dallas. Methylation changes are a reliable marker because they can be detected easily in postmortem tissue due to their covalent bonds, said Monteggia, who has also studied the epigenetics of suicide and depression. However, methylation is not the only mechanism for change in DNA, she added. Other mechanisms of epigenetic change are not so easy to track in an autopsy, she said. Phosphorylation or acetylation are more difficult to compare because of the more transient nature of those traits. The McGill researchers also took a closer look at a cluster of four genes displaying particularly significant methylation differences between the two cohorts. These were the NR2E1 orphan nuclear receptor gene; the CHRNB2 neuronal acetylcholine receptor subunit beta-2 gene; the GRM7 metabotropic glutaminergic receptor 7 gene; and the DBH dopamine beta-hydroxylase gene. These genes are all related to cell-level processes of learning, memory, behavior, and neuronal communication, such as synaptic transmission. NR2E1 and GRM7 influence behavioral traits such as anxiety, impulsivity, and aggression, all of which are risk factors for suicide. Methylation in those genes may thus affect an individual s ability to respond to psychosocial stress, suggested the authors. CHRNB2 and DBH have been connected with learning and memory formation. The study observed hypermethylation without any difference in DBH gene expression between suicide completers and controls. The authors speculated that the effects of DBH on suicide risk may thus be indirect, working through its role in norepinephrine synthesis. Nevertheless, because suicide is so complex and so much about it remains unknown, it is hard to know precisely how these processes underlie suicide risk factors, said Monteggia. There s still a lot of work that needs to be done to focus into the complex of genes that actually trigger suicidal behavior, she said. For instance, are these genes related to the pathophysiology of suicide or to the ideation or execution of suicide? PN An abstract of Genome- Wide Methylation Changes in the Brains of Suicide Completers is posted at psychiatryonline.org/article. aspx?articleid= HAPA to Meet in San Francisco The Hellenic American Psychiatric Association (HAPA) will hold its 14th annual meeting in conjunction with APA s 2013 annual meeting in San Francisco. It will take place on Tuesday, May 21, from 6 p.m. to 8 p.m. at the San Francisco Marriott Marquis. The meeting will feature two special presentations: The Women s Mental Health Clinic at Eginition Hospital, Athens, Greece: The First 10 Years by Iannis Zervas, M.D., an associate professor of psychiatry at Athens University Medical School and chief of the Women s Mental Health and Perinatal Psychiatry Clinic at Eginition Hospital; and Improving the Quality of Medical Education Worldwide: The Contributions of the Educational Commission for Foreign Medical Graduates (ECFMG) and Foundation for Advancement of International Medical Education and Research (FAIMER) by Emmanuel Cassimatis, M.D., president and CEO of the ECFMG and chair of the Board of Directors of FAIMER. A Dutch treat dinner at a local restaurant will follow the meeting. Those interested in attending the meeting and dinner must register and pay dues $52 for members and $25 for members-in-training. Dues should be mailed to Maria T. Lymberis, M.D., 1500 Montana Avenue, #201, Santa Monica, Calif More information is available by ing Lymberis at maria@lymberis.com. PN

30 Medical Director/ Consultation-Liaison Psychiatrist Psychosomatic Medicine Service Atlantic Health System Morristown Medical Center, Morristown, New Jersey Atlantic Health System is on the forefront of medicine, setting standards for quality healthcare in New Jersey and beyond. We are currently seeking a full time Psychiatrist to oversee our psychiatric consultation/liaison (psychosomatic medicine) service to meet the needs of the medical center. In addition to this full time position, the psychosomatic medicine service is comprised of another full time psychiatrist and a half time psychiatrist, a full time advanced practice nurse and full time social worker. There are also research and scholarly opportunities in psychosomatic medicine. Position reports to the Chairman, Dept of Psychiatry and Behavioral Health. Must be Board-certi ed in Adult Psychiatry and be Fellowship-trained in Psychosomatic Medicine, or have signi cant experience in consultation in the general medical setting. Will need a NJ medical license. We offer an environment that is both state-of-the-art and patient centric. Morristown is a desirable suburban community known for its excellent schools and is ideally located less than one hour from New York City. Please send letters of interest with CV to: Thomas.Zaubler@atlantichealth.org; For more details and to apply, please visit our website: atlantichealth.org/careers (Req #79853) Morristown Medical Center We are an Equal Opportunity Employer Magnet is a registered trademark of the American Nurses Credentialing Center. FORTUNE is a registered trademark of Time Inc. and is used under license. FORTUNE and Time Inc. are not af liated with, and do not endorse products or services of, Licensee. New facility, unique leadership opportunity to develop model mental health services EXCEL We can make that happen. Medical Director Opportunity The University of Kentucky (UK) is seeking a highly qualified psychiatrist with demonstrated management experience to lead a new, state-of-the-art mental health facility in Lexington, Kentucky. As Medical Director of Eastern State Hospital, you will play a key role in the University s innovative partnership with the Commonwealth of Kentucky to manage the newly constructed, $129 million facility located at UK s Coldstream Research Campus. The Medical Director will join the UK HealthCare leadership team in developing a recovery-focused and patient-centered treatment model. Plans for this adult-only hospital include the development of an acquired brain injury unit and transitional residential units on the campus. This position offers the ideal candidate with a unique opportunity to achieve excellence across the full continuum of mental health services. Medical Director, Eastern State Hospital Eastern State Hospital, University of Kentucky HealthCare The Medical Director will direct and coordinate the daily activities of the Medical Clinic, Laboratory, Quality and Safety, and Risk Management areas. The candidate should have knowledge of evidencebased treatments, understand principles of trauma-informed care and have a strong desire to work in an environment that promotes peer-mediated supports and full partnerships with advocacy groups and community providers. The Medical Director must be licensed to practice medicine by the Kentucky Board of Medical Licensure, hold a valid DEA license, be Board Certified in Psychiatry and possess at least three years of Administrative experience and five years of Clinical experience. To apply or for more information regarding requisition SV545627, please visit us online at: and click UK Jobs Search & Apply If you have questions, contact HR/Employment, phone (859) press option 2 or ukjobs@ .uky.edu. Application deadline is Sunday, May 19, Saint Francis Behavioral Health Group is seeking a BC Psychiatrist to lead its dedicated psychiatric team at Johnson Memorial Hospital, a 92-bed Community-based acute care hospital located in Stafford Springs, Connecticut. In this role, you ll lead and oversee the delivery of behavioral health care in the inpatient unit, outpatient service and emergency department. Additionally, the Medical Director will provide clinical care to patients, lead the development of a multidisciplinary team, ensure compliance with policies and regulatory requirements, and work with other clinical and support services to ensure behavioral health objectives are met system wide. This position involves a mix of clinical and administrative duties. Join us, and use your collaborative and business development skills to lead the program s growth while establishing and maintaining best practices in patient care. The Stafford Springs area is a welcoming blend of rural and suburban living, rich in New England history, culture and recreation. Hartford, Manchester and Enfield are close by and Boston and New York are within easy driving distance. Bring your vision and desire to excel in a behavioralal health leadership role to JMMC. Contact Christine Bourbeau, Director of Physician Recruitment, today at , or your CV and letter of interest to CBourbea@stfranciscare.org for immediate consideration. EEO-AA-M/F/D/V Pre-Employment Drug Testing The University of Kentucky is an Equal Opportunity Employer and encourages applications from minorities and women. To learn more about this opportunity, visit:

31 26 Psychiatric news May 3, 2013 Insurance Implications continued from page 12 Q A How are DSM-5 and ICD related? DSM-5 and the ICD should be thought of as companion publications. DSM-5 contains the most up-todate criteria for diagnosing mental disorders, along with extensive descriptive text, providing a common language for clinicians to communicate about their patients. The ICD contains the code numbers used in DSM-5 and all of medicine, needed for insurance reimbursement and for monitoring of morbidity and mortality statistics by national and international health agencies. APA works closely with staff from the WHO, CMS, and CDC- NCHS to ensure that the two systems are maximally compatible. Q How is information from DSM-5 used? A DSM-5 is the handbook used by health care professionals in the United States and much of the world as the authoritative guide to the diagnosis of mental disorders. Clinicians use DSM-5 diagnoses to communicate with their patients and with other clinicians and to request reimbursement from insurance organizations. DSM-5 diagnoses may also be used by public health authorities for compiling and reporting morbidity and mortality statistics. Another important role of DSM is to establish diagnoses for research on mental disorders. Only by having consistent and reliable diagnoses can researchers determine the risk factors and causes for specific disorders and determine their incidence and prevalence rates. Q Can clinicians continue to use the DSM-IV-TR diagnostic criteria? THWACK. THE SOUND OF YOUR PATIENT RUNNING UP AGAINST SCHIZOPHRENIA SYMPTOMS. FANAPT MAY HELP. Paraphilias continued from page 10 itself does not automatically justify or require clinical intervention; in fact, a paraphilia is not a diagnosis. To warrant the diagnosis of paraphilic disorder, an individual must meet criterion A and criterion B, the latter indicating that the paraphilia causes distress or impairment in functioning or that the sexual practice inherently involves nonconsenting individuals. Blanchard said the distinction corrects what he called a logical absurdity in the DSM-IV criteria. The previous criteria require that a person having a paraphilia be in distress, he said. So if you think about it, according to the criteria the only transvestite is an unhappy transvestite. You could have a man who cross-dresses for sexual gratification three times a week, but if he s not unhappy about it, he s not a transvestite. The change to the manual recognizes that you could practice sexual masochism or cross-dressing without having a mental disorder, he said. The two routes to upgrading a paraphilia to a paraphilic disorder are either because it causes distress or impairment in functioning or because the paraphilia inherently involves individuals who are nonconsenting and who have been used to gratifying the paraphilia in real life and not just in fantasy. PN A fact sheet on paraphilic disorders can be accessed by scanning the QR code with your smartphone or going to psychiatry.org/dsm5. Efficacy FANAPT significantly improved overall symptoms in 2 clinical trials, as measured by the Positive and Negative Syndrome Scale (PANSS) (4-week trial) and the Brief Psychiatric Rating Scale (BPRS) (6-week trial) 1 Tolerability Discontinuation rates due to adverse events were similar for FANAPT (5%) and placebo (5%) 1 * The most common adverse reactions were dizziness, dry mouth, fatigue, nasal congestion, somnolence, tachycardia, orthostatic hypotension, and weight increase 1 EPS /Akathisia Incidence of EPS and akathisia was similar to placebo 1 * INDICATION FANAPT is an atypical antipsychotic agent indicated for the treatment of schizophrenia in adults. In choosing among treatments, prescribers should consider the ability of FANAPT to prolong the QT interval and the use of other drugs first. Prescribers should also consider the need to titrate FANAPT slowly to avoid orthostatic hypotension, which may lead to delayed effectiveness compared to some other drugs that do not require similar titration. IMPORTANT SAFETY INFORMATION WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analysis of seventeen placebo-controlled trials (modal duration 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in the drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. FANAPT is not approved for the treatment of patients with dementia-related psychosis. Please see additional Important Safety Information and brief summary of Prescribing Information, including Boxed WARNING, on adjacent pages.

32 27 A Clinicians may use DSM-5 in their practices when the manual is released May 22. However, there may be brief delays while insurance companies update their claim forms and reporting procedures to accommodate DSM-5 changes, and clinicians should use DSM-IV-TR diagnoses and codes when required by a specific company. Transition details are still being developed with CDC-NCHS, CMS, and private insurance agencies. APA is working with these groups with the expectation that a transition to DSM-5 by the insurance industry can be made by December 31, As part of the transition to DSM-5, there will also need to be updates of questions in board certification examinations and quality assessments for medical-record reviews. APA will provide periodic updates of agreements with federal agencies, private insurance companies, and medical examination boards as they become available. PN The CMS response to an FAQ about the relationship between DSM and ICD-9-CM is posted at php?id=5005&faqid=1817. This response will be updated to reflect the transition to DSM-5 as soon as it is released. Metabolics Mean change in weight from baseline at end point for FANAPT patients was 2.1 kg across all short-term and long-term trials 1 The majority of patients taking FANAPT 24 mg/day did not experience a shift from normal to high in fasting lipid measurements in a 4-week study 1 Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics Dosing flexibility Efficacy demonstrated at 6 mg twice daily, with dosing flexibility up to 12 mg twice daily 1 START YOUR PATIENTS ON FANAPT FOR FREE. FANAPT vouchers are good for 34 days (68 tablets) of FANAPT. Vouchers are available for download at *Based on pooled data from 4 placebo-controlled, 4- or 6-week, fi xed- or fl exible-dose studies. Extrapyramidal symptoms. Percentage of patients who experienced weight gain of 7% of body weight was 12% for FANAPT mg/day and 18% for FANAPT mg/day versus 4% for placebo. 3.6% of patients taking FANAPT 24 mg/day experienced a shift from normal (<200 mg/dl) to high ( 240 mg/dl) in fasting total cholesterol versus 1.4% of patients taking placebo. 10.1% of patients taking FANAPT 24 mg/day experienced a shift from normal (<150 mg/dl) to high ( 200 mg/dl) in fasting triglycerides versus 8.3% of patients taking placebo. IMPORTANT SAFETY INFORMATION Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/ cerebrovascular risk. These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain. While all atypical antipsychotic drugs have been shown to produce some metabolic changes, each drug in the class has its own specific risk profile. FANAPT is a registered trademark of Vanda Pharmaceuticals Inc. and is used by Novartis Pharmaceuticals Corporation under license. FANAPT is licensed by Novartis Pharmaceuticals Corporation from Titan Pharmaceuticals, Inc. Reference: 1. FANAPT [prescribing information]. East Hanover, NJ: Novartis Pharmaceuticals Corp; January Novartis 5/12 FNP