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2014
Syllabus &
Proceedings
Summary
Integrating Science and Care in
a New Era of Population Health
American Psychiatric Association
66th Institute on Psychiatric Services
San Francisco, CA | Marriott Marquis
October 30 – November 2, 2014
APA’s Leading Educational Conference on
Public, Community and Clinical Psychiatry
CONTENTS
Courses and Seminars ………..
1
Innovative Programs …………..
4
Forums …………..……………...
10
Lectures …………..…………….
13
Symposia …………..…………...
21
Workshops …………..………….
35
Posters
Session 1 …………………
52
Session 2 …………………
71
Session 3 …………………
91
Session 4 …………………
110
© Copyright 2014. All rights reserved. No part of this work may be reproduced or utilized in any form by any means, electronic or
mechanical, including photocopying, microfilm, and recording or by any other information storage and retrieval system, without written permission from the
American Psychiatric Association.
2014 INSTITUTE ON PSYCHIATRIC SERVICES
Courses and Seminars
SEMINARS
COURSE
OCT 30, 2014
OCT 30, 2014
THE INTEGRATION OF PRIMARY CARE AND
BEHAVIORAL HEALTH: PRACTICAL SKILLS FOR
THE CONSULTING PSYCHIATRIST: NEW
ADVANCED COURSE
CPT CODING
Director: Allan A. Anderson, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand CPT coding procedures and terminology; and 2) understand the new AMA/CMS guidelines.
SUMMARY:
This seminar is for both clinicians (psychiatrists, psychologists, social workers) and office personnel who either provide
mental health services or bill patients for such services using
"Current Procedural Terminology (CPT) codes, copyrighted
by the American Medical Association. Seminar attendees are
encouraged to obtain the most recent published CPT Manual
and read the following sections: 1) the Guideline Section for
Evaluation and Management codes, 2) the Evaluation and
Management codes themselves, and 3) the section on
"Psychiatry." The objectives of the seminar are twofold: first,
to familiarize the attendees with all the CPT codes used by
mental health clinicians and review issues and problems
associated with payer imposed barriers to payment for
services denoted by the codes; second, the attendees will
review the most up-to-date AMA/CMS guidelines for
documenting the services/procedures provided to their
patients.
Director: Lori E. Raney, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: Make the case for integrated behavioral health services in primary care, including the evidence for collaborative care; describe the roles for a primary care consulting
psychiatrist in an integrated care team; and, describe
rationale for providing primary care services in the mental
health setting.
SUMMARY:
This course is designed to introduce the role of a psychiatrist
functioning as part of an integrated care team. The first part
of the course describes the delivery of mental health care in
primary care settings and includes the evidence base and
guiding principles. The second part is devoted to reviewing
approaches to providing primary care in mental health
settings and the emerging models in this area. The material
includes a discussion of both the evidence base for this work
and the practical “nuts and bolts” for care delivery. Examples
in diverse locations, emphasis on team building and settings
will also be discussed. Four speakers including Jurgen
Unutzer, M.D. and Anna Ratzliff, M.D., Ph.D. from the
University of Washington, Department of Psychiatry, Lori
Raney, M.D., Chair APA Workgroup on Integrated Care and
John Kern, M.D., Chief Medical Officer, Regional Mental
Health will present didactic material and allow ample time
for questions and discussion.
OCT 31, 2014
APA & ACA, YES WE CAN!
Report of the APA Presidential Task force on Equipping Psychiatrists for the Post-ACA Environment
Director: Anita Everett, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the implications of the ACA for medicine and psychiatry, in particular; and 2) identify relevant
APA resources applicable to one’s practice.
SUMMARY:
Update: Since the passage of the ACA four years ago, numerous opportunities have been created that impact psychiatric
practice. The APA has addressed multiple components of
ACA implementation within existing structures as well as
through expert task forces that address aspects of ACA
implementation. Now we are at a critical point… Moving
forward over the next several years, what themes of the ACA
will remain? what is vulnerable to change? and what do
psychiatrists need to provide the best care to persons with
mental illnesses in the US? Dr. Everett is the current APA
Trustee-at-Large and has participated in multiple APA
initiatives that involve implementation of the ACA. She has
led the implementation of several integrated care projects
within the Hopkins Healthcare System in Baltimore. In this
session, psychiatric aspects of the ACA will be reviewed. ACA
related APA products and resources will be discussed. Most
importantly, we hope to have a robust discussion regarding
how ACA has impacted the practice of psychiatry in the US,
and what the APA and organized medicine can do to
facilitate better practice in the ACA era.
OCT 31, 2014
ESSENTIAL PSYCHOPHARMACOLOGY
Director: Charles DeBattista, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) provide an update on recent advances in psycopharmacology of major disorders; 2) discuss in detail
approaches to the treatment of specific disorders; 3) review
recent studies on pharmacogenetics; 4) provide a rational
basis for selection of medications; and 5) discuss efficacy and
side effects of antipsychotic agents.
SUMMARY:
Psychopharmacology remains a mainstay of psychiatric
treatment. This course reviews recent advances in the treatment of a number of common disorders. In addition to
formal presentations, case examples will be employed and
there will be question and answer periods.
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use for opioid dependence treatment. In addition, other
areas pertinent to office based treatment of opioid
dependence will be included in the seminar (e.g., nonpharmacological treatments for substance abuse disorders,
different levels of treatment services, confidentiality).
Finally, the seminar will utilize case-based, small group
discussions to illustrate and elaborate upon points brought
up in didactic presentations.
FINDING YOUR IDEAL JOB IN PSYCHIATRY
Directors: Wesley E. Sowers, M.D., Robert S. Marin, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe factors impacting career choices and the
personal economics of psychiatrists; 2) develop a life vision
and a strategic plan for career development that is consistent
with it; and 3) negotiate an employment contract that will
support their life vision and personal priorities.
SUMMARY:
This session will enable graduating psychiatric residents and
early career psychiatrists to effectively envision a career they
would find personally satisfying and fulfilling as a first step in
finding their first job or changing positions. It will describe
the health care environment with both the opportunities and
challenges it presents. It will use interactive discussion and
practical exercises to enable participants to articulate a life
vision and an ideal career profile. Having accomplished this,
participants will be engaged in a consideration of how job
searches have typically been conducted by unprepared
applicants and will identify many of the pitfalls that can be
avoided by well-informed applicants who prepare adequately. The evaluation of potential employers and effective
strategies for doing so will be considered along with strategies for negotiating a job description that is consistent with
career goals and desired lifestyle. The session will provide
ample opportunities for participants to discuss their particular questions and concerns, and will provide exposure to
senior psychiatrists who have created careers that have been
highly satisfying and in balance with a rich personal life. it
will emphasize the necessity of taking care of one's self in
order to provide optimal care to persons to be served.
NOV 01, 2014
RECOVERY-ORIENTED CARE IN PSYCHIATRY
Directors: Wesley E. Sowers, M.D., Annelle Primm, M.D.,
M.P.H.
Faculty: Jacquelyn Pettis, M.S.N., R.N.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify principles of integrated, trauma-informed,
culturally appropriate recovery oriented care for people with
mental health and/or substance use conditions and other
complex issues; 2) recognize benefits of a recovery approach
for people working toward recovery as well as psychiatrists;
and 3) apply practical strategies and tools to implement
recovery oriented practices in the clinical setting.
SUMMARY:
This session provides a basic understanding of recovery
from mental illness and substance use disorders and
recovery oriented care. Seminar delivery includes lecture,
discussions, and case studies and uses a collaborative
teaching approach between a psychiatrist and a personal
with lived experience which models the necessary collaborative therapeutic relationship that is essential for the delivery
of optimal mental health care. This session was developed by
the APA in collaboration with the American Association of
Community Psychiatrists as part of SAMHSA's Recovery to
Practice Initiative (RTP) to broaden and increase awareness,
acceptance, and adoption of recovery principles and practices among mental health professionals.
BUPRENORPHINE AND OFFICE-BASED TREATMENT OF OPIOID USE DISORDER
Directors: John A. Renner Jr., M.D., Petros Levounis, M.A.,
M.D.
Faculty: Andrew J. Saxon, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the clinically relevant pharmacological
characteristics of buprenorphine; 2) list at least five factors to
consider in determining if the patient is an appropriate
candidate for office-based treatment with buprenorphine;
and 3) describe the resources needed to set up office-based
treatment with buprenorphine for patients with opioid.
SUMMARY:
The purpose of the seminar is to provide information and
training to participants interested in learning about the
treatment of opioid dependence, and in particular physiccians who wish to provide office based prescribing of the
medication buprenorphine for the treatment of opioid
dependence. Federal legislative changes allow office based
treatment for opioid dependence with certain approved
medications, and Food and Drug Administration (FDA)
approved buprenorphine for this indication. The legislation
requires a minimum of eight hours training such as the
proposed seminar. After successfully completing the
seminar, participants will have fulfilled the necessary
training requirement and can qualify for application to
utilize buprenorphine in office-based treatment of opioid
dependence. Content of this seminar will include general
aspects of opioid pharmacology, and specific aspects of the
pharmacological characteristics of buprenorphine and its
CULTURALLY APPROPRIATE ASSESSMENT
REVEALED: THE DSM-5 OUTLINE FOR CULTURAL
FORMULATION: CULTURAL FORMULATION
INTERVIEW WITH VIDEOTAPED CASE VIGNETTES
Directors: Russell Lim, M.D., Francis G. Lu, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe methods to elicit the cultural conceptualizations of distress after a discussion of the different types of
explanatory models and viewing a videotaped vignette; 2)
describe interviewing techniques to assess the various
aspects of cultural identity after assessing their cultural identity, and viewing videotaped interview.; 3) describe methods
to elicit the stressors and supports as well as cultural features
of vulnerability and resilience of a patient by using a focused
developmental and social history; and 4) discuss and identify
ethno-cultural transference and countertransference after
discussing a journal article and viewing videotaped vignettes
of patients and therapists experiencing both phenomenon.
SUMMARY:
Being able to perform a culturally appropriate assessment is
a skill required by current RRC Accreditation Standards,
including the ACGME core competencies and milestones for
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
all graduating psychiatric residents. In addition, the Institute
of Medicine's (IOM) report, "Unequal Treatment," showed
that patients belonging to minority populations received a
lower level of care than mainstream patients, when matched
for income, insurance status, age, severity of illness. A
culturally appropriate assessment can reduce mental health
disparities by improving the quality of care provided to
minority and underserved groups, improving their engagement, diagnosis, and treatment outcomes. There are many
tools that can be used for a culturally appropriate assessment, such as the DSM-5 Outline for Cultural Formulation
(OCF), and the Cultural Formulation Interview (CFI), and
various mnemonics. The DSM-5 OCF and CFI are excellent
tools for the assessment of culturally diverse individuals.
Both provide a framework to assess cultural identity, cultural
conceptualizations of distress, psychosocial stressors and
cultural features of vulnerability and resilience, the clinicianpatient relationship, and overall cultural formulation. The
seminar will also present Hay's ADDRESSING framework for
assessing cultural identity, Arthur Kleinman's eight questions to elicit an explanatory model, and the LEARN model
used to negotiate treatment with patients. Attendees of the
seminar will learn how to assess their own and their patient's
cultural identities, and how the ethnicity and culture of the
clinician and patient affects transference and counter transference. The seminar will teach clinicians specific skills for
the assessment of culturally diverse patients. Participants
will participate a small group exercise on their own cultural
identities, and then will view mini lectures on the five parts
of the DSM-5 Outline for Cultural Formulation, and the
corresponding questions from the Cultural Formulation
Interview, as well as instruction on interview skills, supplemented by the viewing of taped case examples. Discussion of
the case vignettes will enable attendees to gain an understanding of the skills demonstrated in the videotaped
vignettes. Participants will be encouraged to share their own
approaches, and then modify their approaches based on
material presented in the seminar. Clinicians completing
this seminar will have learned interviewing skills, including
the use of the DSM-5 OCF and CFI, useful in the culturally
appropriate assessment, differential diagnosis, and treatment planning of culturally diverse patients.
magnetoencephalography brain imaging of 2 yogic breathing
techniques (one for treating OCD and its inactive control
correlate) will be presented along with other novel studies in
mind-body medicine based on yogic concepts and
techniques. Participants will practice and learn to implement
select disorder- and condition-specific meditation techniques for inducing a meditative state, "energizing," facing
mental challenges, one specific for OCD, a breathing
technique for generalized anxiety disorders, a 3-minute
technique to help manage fears, an 11-minute technique for
anger, a 3-minute technique to help focus the mind, 2
different meditation techniques specific for depression (one
for 11 minutes and the other for 15 minutes), an 11-31
minute technique for addictions, a 11 minute technique for
ADD/ADHD, one for releasing childhood anger, and one
useful for PTSD and other traumatic events. Participants will
also be taught how to formulate short protocols for patients
that want to include these techniques in their treatment
protocol as either a complement to medication, medication
resistance, or electing to forgo medication. Complete
protocols will be taught for OCD, ADHD, PTSD, and major
depressive disorder. Ample time will be given to answer
questions and to discuss the participant's personal experiences of the techniques during the seminar. Participants will
be sitting in chairs. No prior experience with yoga or
meditation is necessary.
FRONTIERS IN CLINICAL WORK WITH PEOPLE
WHO ARE HOMELESS
Director: Stephen M. Goldfinger, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of this course, the participant should be
able to: 1) demonstrate an understanding of the interactions
and history of mental illness, poverty, substance abuse and
homelessness; 2) provide social, psychological and structural
interventions to improve the lives and functioning of individuals who are homeless and mentally ill; and 3) identify five
ways to more successfully help individuals receive housing
and entitlements.
SUMMARY:
This training course will bring together many of the national
leaders who provide mental health services to individuals
who are homeless and have serious mental illnesses, organize these services, or do research on issues affecting this
population. We who are involved love this work, and our goal
is to encourage more mental health professionals to work
with people who are homeless with serious mental illnesses
and with the organizations that provide services and support
to this population. The format will include a combination of
formal presentations, clinical consultations, and interactive
panels; clinicians, academics, consumers, residents, and
policymakers. Participants will also have the opportunity to
discuss strategies with their colleagues across disciplines and
gain a deeper understanding of diverse approaches to
dealing with people who are homeless and have mental
illnesses.
KUNDALINI YOGA MEDITATION TECHNIQUES FOR
ANXIETY DISORDERS INCLUDING OCD,
DEPRESSION, ADHD, AND PTSD
Director: David Shannahoff-Khalsa, B.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) teach others specific meditation techniques for
treating OCD, anxiety disorders, depression, grief, fear,
anger, addictions, PTSD, and ADHD; 2) understand
published results showing efficacy for new and treatment
refractory OCD and OC spectrum disorders and comorbid
patients; and 3) understand novel yogic concepts and
techniques in mind-body medicine now published in peerreviewed scientific journals.
SUMMARY:
Two clinical trials will be presented that used Kundalini yoga
meditation techniques specific for treating OCD. The first is
an open trial with a 55% improvement on the Y-BOCS
(International Journal of Neuroscience 1996) and the second
is a RCT (CNS Spectrums 1999) with a 71% mean group
improvement on the Y-BOCS. Whole-head, 148-channel
PRIMARY CARE SKILLS FOR PSYCHIATRISTS
Directors: Erik R. Vanderlip, M.D., Lori E. Raney, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the causes of excess mortality in the
SMI population and discuss lifestyle modifications that are
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AMERICAN PSYCHIATRIC ASSOCIATION
useful; 2) understand the current state of the art in treating
diabetes, hypertension, dyslipidemias, smoking cessation
and obesity; 3) develop skills in understanding the use of
treatment algorithms for chronic illnesses; 4) explore the use
of a primary care consultant to assist in treatment of patients
if prescribing desired; and 5) discuss the rationale for
psychiatrist prescribing with emphasis on liability and scope
of practice concerns.
SUMMARY:
Patients with mental illness, including those with serious
mental illness (SMI), experience disproportionately high
rates of tobacco use, obesity, hypertension, hyperlipidemia
and disturbances in glucose metabolism. This is often
partially the result of treatment with psychiatric medications. This population suffers from suboptimal access to
quality medical care, lower rates of screening for common
medical conditions and suboptimal treatment of known
medical disorders such as hypertension, hyperlipidemia and
nicotine dependence. Poor exercise habits, sedentary lifestyles and poor dietary choices also contribute to excessive
morbidity. As a result, mortality in those with mental illness
is significantly increased relative to the general population,
and there is evidence that this gap in mortality is growing
over the past decades. Because of their unique background
as physicians, psychiatrists have a particularly important role
in the clinical care, advocacy and teaching related to
improving the medical care of their patients. As part of the
broader medical neighborhood of specialist and primary are
providers, psychiatrists may have a role in the principal care
management and care coordination of some of their clients
because of the chronicity and severity of their illnesses,
similar to other medical specialists (nephrologists caring for
patients on dialysis, or oncologists caring for patients with
cancer). There is a growing need to provide educational
opportunities to psychiatrists regarding the evaluation and
management of the leading cardiovascular risk factors for
their clients. This seminar provides an in-depth, clinically
relevant and timely overview of all the leading cardiovascular
risk factors which contribute heavily to the primary cause of
death of most persons suffering with SMI.
Innovative Programs
INNOVATIVE PROGRAM 1
and the strategies and challenges involved with its
implementation. This will be followed by a discussion with
the panelists.
References:
THE EFFECTS OF TRAUMA: A REVIEW OF THE
ADVERSE CHILDHOOD EXPERIENCES STUDY AND
THE IMPLEMENTATION OF TRAUMA INFORMED
CARE


Chair: Lawrence Malak, M.D.
Presenter: Dawn Griffin, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) specifics of the ACE Study and the
findings on Medical and Mental Health in adults; 2) background on trauma informed care; and 3) implementation of
trauma informed care at county level.
SUMMARY:
The effect and prevalence of traumatic events in the lives of
those with psychiatric disorders has long been known to be
greater than general population. However the extent of those
effects in both psychiatric and medical condition had not
been well defined. The Adverse Childhood Experiences Study
is an ongoing collaborative, multi-site study looking at the
effect of adverse childhood experiences on many aspects of
adult health. The study has looked at over 17,000 patients at
multiple sites and has been led by Dr. Felitti and Dr. Anda.
There have been numerous results produced from this study
highlighting a link between increased medical issues and
mental health issues in those with significant ACE scores.
Those with an ACE have an increased risk for smoking,
obesity, HIV/AIDS, suicide attempts and alcohol abuse,
among other findings. As we have become increasingly
aware of the effects of trauma, shift towards Trauma
Informed Care has taken hold. It's principles center on
acknowledging and trauma and its impact on the whole
person on their way to recovery. Dr. Griffin is implementing
Trauma informed care in the San Diego County system,
focusing on integrated care and examining all aspects of care
through a trauma lens. The presentation will start with
background of the ACE studies and presentation of the
results, followed by background on Trauma informed care




http://acestudy.org/home
Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM,
Edwards V, Koss MP, et al. The relationship of adult health status to
childhood abuse and household dysfunction. American Journal of
Preventive Medicine. 1998; 14:245-258.
Felitti VJ, Anda RF. The Relationship of Adverse Childhood
Experiences to Adult Health, Well-being, Social Function, and Health
Care. Chapter 8 in The Effects of Early Life Trauma on Health and
Disease: the Hidden Epidemic; Editors: Lanius R, Vermetten E, Pain
C. Cambridge University Press. 2010
Felitti, V. & Anda, R. (2010). The relationship of adverse childhood
experiences to adult medical disease, psychiatric disorders, and
sexual behavior: Implications for healthcare. In R. A. Lanius, E.
Vermetten, & C. Pain, Eds., The hidden epidemic: The impact of
early life trauma on health and disease. Cambridge University Press.
NY: Cambridge University Press.
van der Kolk, B, McFarlane, A, & Weisaeth, L. (2007).
Traumatic Stress: The Effects of Overwhelming Experience on Mind,
Body, and Society. New York: The Guilford Press.
INNOVATIVE PROGRAM 2
GAMBLING: FROM IMPULSE CONTROL TO NONSUBSTANCE ADDICTION: EPIDEMIOLOGY,
NEUROBIOLOGY, DIAGNOSIS AND TREATMENT
Chair: Vishesh Agarwal, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) improve awareness among psychiatrists, psychotherapists and other clinicians about gambling disorder for
early identification and intervention; 2)educate about identification and diagnosis of gambling disorder; 3) educate and
discuss available resources for treatment of gambling
disorder.
SUMMARY:
Background: Pathological gambling was added to the DSM in
1980. The DSM-5 renamed it as "Gambling Disorder" and
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
placed it with "Substance-Related and Addictive Disorders."
It is the only "behavioral addiction" in this group. This was
done for good reason. Research has shown association of
gambling disorder with other medical, psychiatric and social
problems. More and more scientific literature has revealed
the commonalities between gambling and substance-use
disorders. Purpose: To educate and discuss about the
pathology, diagnosis and treatment options of gambling
disorder. Methods: Literature review from PubMed and data
reviewed from the American Gaming Association (AGA),
National Council on Problem Gambling (NCPG), Center for
Gaming Research and other sources. Results: Since 1975, the
proportion of adults who have never gambled has dropped
from 1 in 3 to 1 in 7. An estimated 4% of US adult population
meets criteria for problem gambling. Some form of legalized
gambling exists across all states of United States except
Hawaii and Utah. The total revenue generated from all forms
of gambling is close to $100 billion, which is higher than all
other major forms of entertainment combined. Annual social
costs related to gambling disorder are estimated at $7 billion.
Diagnosis and treatment: Unlike substance use disorders,
gambling disorder does not have a laboratory test and
routine screening is not common. Various screening tools
are available including South Oaks Gambling Screen (SOGS),
Gambling Symptom Assessment Scale (G-SAS) and
Gambling Addiction Index (GAI), but they are not frequently
used and there is limited evidence on their validity and
reliability. Various psychosocial approaches have been
studied and evidence varies on their success. Cognitive
therapy, behavior approaches and motivational interviewing
have shown good evidence; others such as 12 step approach,
self-help groups Gamblers Anonymous (GA) and self
exclusion have also been found to be useful. There is no FDA
approved pharmacological treatment and little evidence
exists on some agents that have been studied. Conclusion:
Gambling disorder is a serious addiction and its prevalence
appears limited because it may present as a co-morbid
illness. The magnitude of this disorder is not clearly defined
as routine screening is not performed. The limited treatment
options available need to be further studied.
tise required to meet their needs, but its implications for the
deaf and hard of hearing has not been extensively studied.
Community Behavioral Health, a community mental health
center in the Eastern Shore of Maryland, has collaborated
with the Core Service Agency to obtain telepsychiatry
equipment for the deaf and hard of hearing with the
assistance of an HRSA grant from Gallaudet University. This
innovative equipment utilizes the assistance of a social
worker from Arundel Lodge who is culturally competent in
American Sign language. This workshop will explain the role
of a clinician in obtaining, creating, and managing logistical
necessities to allow effective delivery of mental health
services to the deaf and hard of hearing in rural regions.
OCT 31, 2014
INNOVATIVE PROGRAM 3
CET (COGNITIVE ENHANCEMENT THERAPY): AN
EBP THAT IMPROVES SOCIAL COGNITION,
VOCATIONAL SUCCESS AND PHYSICAL HEALTH
Chair: Ray Gonzalez, M.S.W.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the critical role that neuroplasticity
and cognitive remediation play in the recovery process;
2)recognize the importance of treating cognitive deficits
(processing speed, working memory, executive functioning)
and social cognition in persons with schizophrenia, bipolar
disorder and depression; 3) state the theoretical constructs
underlying CET and why CET as a one-time intervention has
shown to be very durable (improvements maintained at 12+
years) with 85% attendance and graduation rates; 4) Discuss
how CET can increase physical health in a Health Home by
improving cognitive functioning of persons recovering from
mental illness so they can be better primary care patients;5)
Explain how CET, with its emphasis on increasing social
cognition and awareness of work place norms can facilitate
vocational success, especially job retention.
SUMMARY:
There are very few truly active treatment programs to help
individuals with a diagnosis of schizophrenia or bi-polar
disorder in their recovery process. Most treatment/services
are maintenance programs. Since 2001, CET (Cognitive
Enhancement Therapy), a SAMHSA recognized Evidence
Based Practice form of cognitive remediation, has been
successfully disseminated to 27 sites in ten states. During 48
once-a-week sessions of computer exercises, social cognition
groups and individual coaching, over 1,000 clients have
learned how to be socially wise and vocationally effective.
CET groups average 85% attendance and graduation rates
during the year-long treatment process. CET connects with
stable patients like no other treatment program and has
demonstrated increased medication compliance. Attendees
will learn how CET promotes recovery by participating in a
typical CET session including specialized computer exercises; a social cognition talk followed by completing and
discussing homework questions; and completing an interactive cognitive exercise. A PowerPoint talk will describe the
neuroscience research supporting CET; the social, vocational
and educational effectiveness of CET; using CET with a wide
range of individuals (adults, Transitional Aged Youth, persons with high- level autism); and how CET is effective with
person from diverse ethnic and socio-economic back-
A CLINICIAN'S GUIDE TO CREATING A TELEPSYCHIATRY PROGRAM FOR THE DEAF AND
HARD OF HEARING
Chairs: Suni N. Jani, M.D., M.P.H., Sheena Patel, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the needs of the deaf and hard of
hearing in a mental health evaluation; 2)identify rural
regions with underserved populations of deaf and hard of
hearing mental health patients; 3) understand how to
acquire specialized telepsychiatry equipment for the deaf
and hard of hearing; 4) understand how to manage specialized telepsychiatry equipment for the deaf and hard of
hearing; and 5) understand future possibilities and implications for research in telepsychiatry for the deaf and hard of
hearing.
SUMMARY:
Telepsychiatry has been recently approved for some Medicaid and state-funded services to people who have mental
health, developmental disabilities as well as substances
abuse needs or difficulties. It is a well-established and wellstudied method of delivering behavioral health services to
individuals who do not have ready local access to the exper5
AMERICAN PSYCHIATRIC ASSOCIATION
Support Worker, will present data on the program's Community Support Worker peer support position including
details on the peer training experience and impact of the
Community Support Worker role. The panel will conclude by
providing an overview on new hepatitis C treatments and
implications for mental health support and psychiatric care
of patients undergoing hepatitis C treatment now and in the
future. Case discussions will be used to initiate the large
group discussion. Copies of program materials will be
disseminated during the symposium.
grounds. This presentation will demonstrate the hope and
practical wisdom that CET offers including how acceptance
and adjustment to a psychiatric disability can improve
physical health, independence, vocational effectiveness and
social cognition. Lessons learned from disseminating CET to
a wide range of sites ranging from freestanding clinics to
state hospital to large mental health centers will be
presented.
MANAGING PSYCHIATRIC ILLNESS AND HEPATITIS C: COMMUNITY PROGRAMS AND INTERVENTIONS TO OVERCOME SUBSTANCE USE AND
PSYCHOSOCIAL BARRIERS
EXPANDING ACCESS TO TRANSGENDER
SURGERIES TO LOW INCOME PATIENTS:
LESSONS FROM IMPLEMENTATION FOR MENTAL
HEALTH AND PRIMARY CARE PROVIDERS
Chair: Shannon Taylor, R.N.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify gaps in psychosocial care of marginalized
patients with hepatitis C; 2)apply strategies to support the
mental health needs of people living with hepatitis C and/or
undergoing treatment, including: group therapy, peer
support, and psychiatric management by specialists; and 3)
understand the benefits of a multi- disciplinary approach to
psycho-social support for patients with hepatitis C.
SUMMARY:
Mental health and substance use issues have historically
been significant barriers for treating patients with hepatitis
C, especially in tertiary care settings. These requirements
have limited hepatitis C treatment to only a select group of
patients with tri- morbidity (psychiatric illness, substance
use and hepatitis C). The latest hepatitis C treatment guidelines recommend interdisciplinary models of care that
employ harm reduction principles and which research has
documented can achieve comparable hepatitis C treatment
response rates to patients without active substance use. The
recent addition of novel hepatitis C treatments have further
complicated drug regimens and have placed greater emphasis on hepatitis C adherence and the need for improved
patient engagement in overall physical and psychosocial
treatments. This session will provide participants with an
overview of the barriers to and recent advances in Hepatitis
C care, focusing on the gaps in psychosocial care of
marginalized patients with hepatitis C. The symposium will
focus on a collaborative hepatitis C care model, called the
Toronto Community Hep C Program (TCHCP), an interdisciplinary, community- based, harm reduction model of
hepatitis C treatment and support for people with serious
mental health issues and/or ongoing substance use. The
anchor of the TCHCP is a group psycho-education program
that supports patients with multiple psychiatric and physical
co-morbidities. Based upon research and evaluation data
from the TCHCP, we will present four research papers
(published or under review). The symposium will begin with
an overview of the TCHCP model and the core interprofessional programs offered to patients treated in this multi-site
model. Dr. Susan Woolhouse will present retrospective data
on hepatitis C treatment outcomes and qualitative data
illustrating how group structure and cohesion facilitated
behavioural change. Ms. Zoe Dodd, Group facilitator, will
present data on group psychotherapy outcomes, including a
summary of key group therapy factors unique to this group.
Dr. Sanjeev Sockalingam will present on the role of psychiatrists in this integrated model and will report on hepatitis C
and psychiatric outcomes for patients with severe mental
illness and active substance use. Robert McKay, Community
Chairs: Dan H. Karasic, M.D., Julie Graham, M.Sc.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand principles of mental health assessment of transgender patients for surgery, in accordance with
the Standards of Care 7 of the World Professional Association
for Transgender Health; 2)appreciate psychosocial issues of
concern in assessment and preparation for transgender
surgeries for low income patients in public health settings; 3)
understand benefits and risks of medical and surgical
transition-related care for transgender patients; 4) understand key challenges in developing transgender care
programs in community mental health and primary care
settings.
SUMMARY:
In 2013, the San Francisco Department of Public Health
implemented a program to provide medically necessary
transgender surgeries to low income patients under Healthy
San Francisco (a program for those otherwise uninsured)
and MediCal. This expansion of access will be implemented
statewide in 2014, with the expansion of MediCal under the
Affordable Care Act, and with the State of California's
mandate that MediCal (as well as private insurance) cover
these procedures. Recognizing that patients in its public
medical and mental health clinics requiring surgery have
psychosocial needs that must be addressed to assure optimal
outcomes, an interdisciplinary team of medical and mental
health providers, social workers, administrators, and transgender health advocates have devised protocols and educational programs for providers and patients. This workshop
will discuss this innovative program, and principles of
assessment and preparation for transgender surgery for low
income patients in community mental health and primary
care settings.
INNOVATIVE PROGRAM 4
CLOSING THE QUALITY GAP: IMPROVING
QUALITY OF CARE FOR PATIENTS WITH SERIOUS
MENTAL ILLNESS THROUGH A PROVIDER-DRIVEN
CARE DELIVERY DESIGN
Chairs: Sonia Tyutyulkova, M.D., Ph.D., Jennifer B.
Greenspun, L.C.S.W., M.S.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) At the conclusion of this session, the participant
should be able to describe a participatory, consensus6
2014 INSTITUTE ON PSYCHIATRIC SERVICES
trains peers to provide supportive services to people with
psychosis and learn to work with clinicians.
SUMMARY:
Parachute NYC, a Medicaid demonstration grant where
peers and providers use Intentional Peer Support (IPS) and
Needs Adapted Treatment Model (NATM) to inform crisis
services that provide opportunities for people to stay in their
lives and recover. IPS is a peer developed model that encourages peers to use relationships to gain new perspectives that
enable them to support and challenge each other to grow.
NATM, a flexible individualized approach widely used in
northern Europe, engages the person in crisis and his/her
networks in a dialogic process from which problems and
solutions organically emerge. Parachute offers a confidential,
peer-operated support line providing mutual understanding
for anyone in a stressful situation; clinician/peer mobile
teams (adapted from NYC's mobile crisis teams) providing a
home visit within 24 hours of crisis referral using NATM to
offer treatment as often as needed for up to one year; and
peer/professional crisis respites where people not at
imminent risk can stay and remain connected to their daily
lives when they need more support than home can provide.
Services are voluntary and any NYC adult resident may use
any or all components. Full service continuity is available.
We will describe system, clinician and peer implementation
perspectives and early research findings.
building, provider-driven approach to quality improvement;
2)At the conclusion of this session, the participant should be
able to describe a systemic approach to quality improvement
for patients with serious mental illness; 3) At the conclusion
of this session, the participant should be able to recognize
the importance of provider and peer engagement in the
design and implementation of quality initiatives.
SUMMARY:
We will present and discuss the quality improvement initiative of a large community mental health system providing a
continuum of services to individuals with serious mental
illness. We will describe an innovative care delivery model
designed using a bottom-up, provider-driven process. In an
organization-wide effort to improve the quality of care for
the population we serve, we formed a workgroup to develop
recommendations for improvement. The workgroup had an
agency-wide representation from: a) different disciplines
(psychiatry, nursing, social work, case management, employment specialist, residential coordinator, psychiatric rehabilitation staff, peer specialist); b) programs (Assertive Community Treatment, residential services, vocational and
psychiatric rehabilitation programs); c) different geographic
locations; d) management level (direct care staff, mid-level
management, executive level). The task before the workgroup was to develop an "ideal" model of care that will
improve the outcomes for patients with serious mental
illness. A framework centered around quality and around the
following concepts was used to guide the workgroup
discussion: a) the fundamental source of quality is in the
person's experience; b) quality is made or lost in the
relationship with a provider; c) a continuous healing
relationship is a central element of quality; d/ care organized
around patient's needs. We used a participatory, consensus
building, deliberative process, including agency-wide feedback on the model the workgroup developed. We will discuss
the "ideal" care delivery design developed by the workgroup
and some of the barriers to implementation that we
identified. The "ideal" system of care we envisioned is
consistent with the principles of lean design and culture, a
quality improvement approach focused on increasing value
and decreasing waste. We will describe the implementation
of an appropriate organizational infrastructure to support
the model. We will discuss the potential of the model to
improve the effectiveness, efficiency, safety, timeliness and
person-centeredness of care. We will examine the implications of a bottom-up, provider- driven approach for
successful implementation and sustainability, and its
potential advantages over top- down, policy-driven models.
INNOVATIVE PROGRAM 5
INCREASING ACCESSIBILITY TO CARE FOR
RETURNING VETERANS: DELIVERING VA
SERVICES ON A COLLEGE CAMPUS
Chairs: Ellen Herbst, M.D., Keith Armstrong, L.C.S.W.,
Brandina M. Jersky, M.A., Bridget Leach
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify common psychiatric and medical diagnoses observed in Veterans of Operation Enduring Freedom
(OEF), Operation Iraqi Freedom (OIF), and Operation New
Dawn (OND); 2) recognize challenges with treatment
engagement and retention of OEF/OIF/OND Veterans in
traditional models of VA mental health care; 3) learn about
an innovative model of mental health treatment delivery on
a college campus that reduces barriers to care and promotes
treatment engagement among OEF/OIF/OND Veterans.
SUMMARY:
Over two million men and women have served in Operations
Iraqi Freedom (OIF), Enduring Freedom (OEF), and/or New
Dawn (OND). The Post-9/11 GI Bill greatly expanded
educational benefits for these Veterans, resulting in over a
million former service members enrolling in higher education programs. Returning Veterans are at risk for a number of
psychiatric and physical problems, including PTSD, depresssion, anxiety, substance use disorders, chronic pain, and
mild traumatic brain injury (mTBI). Treatment retention
rates of OIF/OEF/OND Veterans in traditional VA Medical
Centers are low. Given the need to provide care to a rapidly
growing population of returning war Veterans, the
development of innovative approaches to reduce barriers to
care, and thus improve treatment delivery, is imperative. The
San Francisco VA Medical Center, in collaboration with City
College of San Francisco (CCSF), developed a program to
conduct outreach to student Veterans, enroll student
Veterans in VA health care, deliver empirically validated
CRISIS AS OPPORTUNITY: HOW PARACHUTE NYC
INTEGRATES PROFESSIONALS AND PEERS TO
IMPROVE OUTCOMES FOR MENTAL HEALTH
CRISES
Chairs: David C. Lindy, M.D., Mary Jane Alexander, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the Needs Adapted Treatment Model
(NATM), its conceptual origins, its literature, and the ways it
has been adapted by Parachute NYC; 2) appreciate the three
components of Parachute NYC (confidential, peer-operated
support line, clinician/peer mobile treatment teams, peer/
clinician respite services) and how they interact; 3) understand the Intentional Peer Support (IPS) model and how it
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AMERICAN PSYCHIATRIC ASSOCIATION
and outside the agency, such as Care Coordination and
Network Providers.
The Call Center is data driven and strives to provide the
highest quality of customer services to the mentally ill. Call
Center staff are trained in crisis response, motivational interviewing, customer services, and technology based training.
We track and trend call data on a daily basis. Currently, the
Call Center telephone responsiveness includes having an 3-4
seconds average speed of answer with a live voice; 98% of
calls answered within 30 seconds; and a call abandonment
rate of only 1.8%. In a continuous effort to use data generated by the Call Center services to improve care of the
mentally ill, new initiatives are tested and put into practice
quarterly. Some of these include identifying the Military/
Veteran and Traumatic Brain Injury (TBI) population to
ensure proper coordination of care; development of a peer
support telephone queue line; and the recruitment of
bilingual staff as an additional enhancement to an already
well diverse Call Center.
mental health treatment, train faculty and administrative
staff on Veterans' issues, and provide social work and care
coordination services, all on the CCSF campus. Initiated in
the fall of 2010, the CCSF Veterans Outreach Program has
delivered VA services to over 1100 student Veterans and
enrolled over 370 Veterans in VA health care, providing
treatment that easily accessible and driven by student
Veterans' needs. We will describe the need to expand this
type of program and provide a conceptualization and
replicable model of care for student Veterans on college
campuses across the country.
INNOVATIONS IN MENTAL HEALTH CARE
THROUGH PSYCHIATRIC CALL CENTER
SERVICES: HOW WE CREATED A DATA DRIVEN
24/7 RESPONSE SYSTEM FOR THE MENTALLY ILL
Chairs: Venkata Jonnalagadda, M.D., Victoria Jackson,
L.C.S.W., M.S.W.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) explain the need for a 12 County 24/7 mental
health call center and how it has evolved into a data driven
state of the art service program; 2)explain the organizational
team structure and logistical operations of a 24/7 mental
health call center; 3) discuss essential call center training to
effectively and efficiently respond to the needs of the mentally ill; 4) explain how a 24/7 call center is a continuous data
driven best care model for identifying unseen needs,
improving internal services, and advocating for mental
health services needed in the community; and 5) discuss
future initiatives for enhancements of a mental health call
center.
SUMMARY:
Eastpointe is a Managed Care Organization (MCO) in the
state of North Carolina that manages, coordinates, and
monitors the mental health, intellectual /developmental
disabilities, and substance use/addiction (MH/IDD/SA)
services in a 12 county region. Eastpointe has been identified
as a 1915 (b) (c) Medicaid Waiver site in the state of North
Carolina. A waiver is an agreement between the state and
Center for Medicaid Services in Washington to be exempted
from certain Medicaid rules. A waiver is necessary for the
state to enter into managed care contracts because of the
transfer of risk (of losing money) from the state to a Managed
Care Organization. It requires the MCO to have an adequate
risk reserve. It requires the Managed Care Organization to
provide organizational functions found in a typical health
insurance plan such Management of the Provider Network,
Quality Management, and Utilization Management. We
authorize payment for Medicaid services for residents who
need MH/IDD/SA services and whose Medicaid originates in
the Eastpointe region. We authorize payment for statefunded services for residents without Medicaid or private
insurance who live in the Eastpointe region. We monitor the
quality of services consumers receive, and handle consumer
concerns and grievances. We provide a toll-free Member Call
Center number for members (individuals within the 12
county region) to access 24 hours a day, 365 days a year. The
Member Call Center is one of the key components of the
Managed Care Organization. The Call Center is responsible
for facilitating access to all supportive, clinical and informational services for members or on behalf of the members
within the Eastpointe catchment area. The Call Center
collaborates closely with other management areas within
A MODEL FOR COMPREHENSIVE CRISIS
SERVICES IN A METROPOLITAN AREA
Chair: Edgar K. Wiggins, M.H.S.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) At the conclusion of this workshop, participants
will be able to identify the essential components of a
comprehensive community crisis service; 2)At the conclusion of this workshop, participants will be able to discuss the
advantages and limitations of the Baltimore City model for
crisis services; 3) At the end of this workshop, participants
will be able to discuss the role that this model has with
intervening with individuals in a suicidal crisis; 4) At the end
of this workshop, participants will be able to identify the role
that the Baltimore City model has with effectively diverting
individuals from psychiatric inpatient care.
SUMMARY:
Baltimore Crisis Response, Inc. (BCRI) has been providing
community based mental health crisis services since 1993.
Initially implemented as a pilot project, BCRI has expanded
over time to include a full range of crisis intervention
services including a 24 hour telephone hotline, mobile crisis
teams, residential crisis beds and in-home services.
Designed to be part of the public mental health system, BCRI
provides services in the least restrictive setting possible
without consideration of the individual's ability to pay. In
2005, BCRI was recognized as one of the three model crisis
programs nationwide. In 2008, The Maryland Disability Law
Center and the Center for Public Representation published a
report entitled "Maryland Citizens in Psychiatric Crisis, A
Report: Improving Emergency Department and Community
Care for People with Psychiatric Disabilities." In this report
the state of Maryland was encouraged to replicate the model
of service delivery provided by BCRI. The strength of the
BCRI model is its full range of services centrally located in
one entity. This results in a uniform standard of care that is
often lacking in decentralized and fragmented services. It
also makes for a more efficient use of resources and allows
for patients to move within the service system should their
clinical picture change. This session will review each service
system component of the BCRI model, including the data for
each component. There will also be a review of the treatment
scope, levels of care protocol, admission criteria, and high
risks issues. Additional discussion will describe the
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
challenges of providing services to a population with a
significant incidence of co-occurring disorders. In addition
there will be a discussion of the specific applications of the
model with regard to patients presenting with a range of
psychiatric symptoms, concerns, and crises. This presentation will also discuss and describe additional specialized
services provided within the scope of this model including:
Results of an eight year police training project (developed
utilizing the National CIT Model), Public education efforts
(utilizing cable and public access television), Response to
critical incidents, and Debriefing and postvention. Finally,
there will be review of the data collected over the past six
years related to a hospital diversion initiative.
that our community psychiatry practice site offers students
and residents a unique practice environment that promotes
patient-centered care with an interdisciplinary educational
approach.
LESBIAN, GAY, BISEXUAL, AND TRANSGENDER
MENTAL HEALTH TRAINING: A NEW PARADIGM
FOR DEVELOPING CLINICAL EXPERTS
Chairs: Weston S. Fisher, M.D., Ellen Haller, M.D., Erick K. J.
Hung, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) appreciate why specialized training is needed to
meet the needs of patients with specific socio-cultural
backgrounds; 2) describe the multiple steps taken by one
academic residency program in its development of specialized training in LGBT mental health; 3) develop ideas for
designing similar specialized training opportunities at their
home institutions including active discussion of the
challenges and opportunities.
SUMMARY:
Many Lesbian, Gay, Bisexual and Transgender (LGBT)
people have unique mental health issues and needs. In
response to the critical need for leaders in LGBT mental
health, the UCSF Adult Psychiatry Residency Training
Program developed an LGBT Mental Health Area of
Distinction. The primary purpose of this specialized training
experience is to prepare interested residents for careers as
leaders in LGBT Mental Health. Participating residents are
required to rotate through specific clinical rotations, review
an LGBT knowledge base, develop scholarly projects, and
present educational material to near peer learners. The steps
taken in developing this specialized Area of Distinction can
be used as a model for other training programs wishing to
offer similar opportunities. Participants in this workshop will
be led through the process of needs assessment, identifying
currently existing opportunities, building a team of
collaborators, identifying core learning objectives and
curricular requirements, and concretizing a final product.
NOV 01, 2014
INNOVATIVE PROGRAM 6
INTERPROFESSIONAL COLLABORATION AND
EDUCATION IN COMMUNITY PSYCHIATRY
Chairs: Kelly Gable, Pharm.D., Mirela D. Marcu, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) Define interprofessional education in the context
of community mental health; 2)Describe an example of a
collaborative practice agreement between a psychiatric
clinical pharmacist and community psychiatrist; 3) Discuss
the implementation of interprofessional education among
pharmacy and medical students and residents in a community mental healthcare setting.
SUMMARY:
Assertive Community Treatment (ACT) is an evidence-based
practice best described as a community mental health
treatment model designed for patients with severe and
persistent mental illnesses. ACT teams consist of a multidisciplinary team of providers that include: a psychiatrist,
social workers, substance abuse specialists, vocational
specialists, nurses, and peer support specialists. ACT has
become a standard of care in community psychiatry since
the movement of deinstitutionalization, yet it is often not
offered as an experiential learning site for medical students
and residents. This program will provide an example of how
a psychiatric clinical pharmacist and community psychiatrist
have developed a collaborative practice agreement that
allows for both clinicians to effectively provide psychiatric
services on two full-fidelity ACT teams. A psychiatric clinical
pharmacist is a pharmacist that specializes in the field of
psychiatry, often including post-graduate education in
psychiatric medicine. Such collaborative agreements are
newer to the field of psychiatry and vary based on individual
state laws. This is the first of its kind in the state of Missouri.
Both clinicians also have academic appointments at schools
of pharmacy and medicine, respectively. Their academic
affiliations allow for forth year pharmacy students, first year
pharmacy residents, third and fourth year medical students,
and third year psychiatry medical residents to be directly
incorporated into their ACT services. Due to the intensive
nature of ACT services, students and residents have the
opportunity to provide care out in the community at
patients' apartments, shelters, and group homes. This
program will describe multiple examples of interprofessional
education that include daily treatment team involvement,
review of patient treatment plans, psychopharmacology
discussions, and psychiatric patient assessments. We believe
CULTURAL DIVERSITY DAY: A RESIDENT INITIATIVE COMBINING CULTURE, EDUCATION, AND
ACTIVISM
Chairs: Kathleen M. Patchan, M.D., Ellen Lee, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) demonstrate understanding of the importance of
culturally informed training for psychiatry residents, using
the DSM-5 as a resource; 2) understand the background
leading to the University of Maryland cultural psychiatry
program, specifically Cultural Diversity Day; and 3) discuss
challenges and implement practical tools for residents,
faculty, and training directors to develop similar programs in
their home institutions.
SUMMARY:
Cultural competency is essential in treating people with
psychiatric disorders. This is demonstrated by the fact that
the DSM 5 has an entire section devoted to culturally specific
formulation. Further, the ACGME requires all psychiatry
residency programs to offer didactics on sociocultural topics
and to teach residents to be culturally sensitive and work
with patient from diverse backgrounds, Nevertheless, many
residency programs do not provide comprehensive
9
AMERICAN PSYCHIATRIC ASSOCIATION
culturally-sensitive programs. In 1993, a diverse group of
psychiatry residents at the University of Maryland School of
Medicine perceived a need for examining cultural issues in
psychiatry. This was prompted by growing tension among
American and international medical graduates and a
perceived lack of sensitivity towards diverse populations.
This led to the creation of the University of Maryland/
Sheppard Pratt Residency program's first Cultural Diversity
Day (CDD). The program has become a popular and novel
event that is developed each year by residents in collaboration with the Residency Training Office. Since its inception
20 years ago, the CDD has evolved into a full day training
opportunity to learn about and discuss culturally-relevant
and often controversial issues that have long-standing
impact. Eminent public speakers around the country have
lectured on relevant topics that have implications both
nationally and abroad. Most recently, programs have
discussed the stigma of mental illness, the interaction of
culture and poverty, the perspective of mental health in
Middle Eastern culture, and the role of military culture on
mental health. Earlier topics have included Latino cultures,
multiracial identity; women's issues; and gay, lesbian, and
bisexual communities. The upcoming CDD will discuss
immigration with a focus on acculturation, parent- child
issues, substance abuse, and suicide. The majority of funding
is provided by the training department but funding is also
provided by fellowship grants such as the, APA/SAMHSA
Minority Fellowship Program awarded to individual
residents. This resident-driven event has been well-received
by the clinical community and has broadened the perspective on cultural issues throughout the residency program and
Department of Psychiatry. The program has also garnered
widespread institutional support and has been attended by
faculty and residents from other departments, the hospital
community, the student body, and the general public.. The
role of this workshop is to discuss the evolution of CDD,
discuss challenges, and to provide comprehensive, yet
practical, tools for other residency programs to develop
culturally diverse events in their home institution. Cultural
sensitivity will become increasingly important as the DSM
continues to evolve and psychiatrists continue to work with
and advocate for patients from diverse populations.
Forums
OCT 30, 2014
contact with any of his family, and though he seems
gregarious and happy in many respects, he is also isolated
and distressed in other ways. Other than the warmhearted
people who leave food next to his shopping cart in the
mornings, he is not currently connected with any community services. Aaron was an active boy growing up, following
in his father's footsteps and playing baseball throughout his
childhood. After he was arrested for unusual behavior in his
late teens, he slowly isolated himself from his family and
friends, and became fixated on the belief that there was an
impending alien invasion. As his thoughts became more and
more troubling, he ended up living in the woods of Northern
California while his father tried unsuccessfully to reach out
for help and to avoid the violent tragedy that would
eventually make national headlines. Psychosis causes some
individuals to reach for care and connectedness with others,
while other people tend to isolate and fall through the cracks.
The narratives of this latter group are frequently lost and are
the focus of this film. By highlighting the human aspects of
psychosis while also addressing the controversial issue of
violence and untreated severe mental illness, Voices captures a uniquely human, honest and raw glimpse of lives
which are frequently confined to the shadows of society.
www.VoicesDocumentary.com
VOICES: A DOCUMENTARY FILM ABOUT HUMAN
AND UNTOLD STORIES OF PSYCHOSIS
Chairs: Gary Tsai, M.D., Rachel Lapidus, M.D., M.P.H.
Presenter: Hiroshi Hara
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) better recognize and understand the issue of
stigma in mental health through film; 2) better recognize and
understand the challenges of family members of individuals
impacted by serious mental illness; and 3) recognize and
identify the role of psychiatrists in advocacy and improving
mental health systems, and how media such as film can be a
powerful medium for mental health advocacy.
SUMMARY:
Voices is a feature length documentary that tells the compelling personal stories of three individuals from very different
backgrounds, all of whom are connected by their experiences with psychotic mental illness. In this state in which
reality is bendable and oftentimes frightening, the resulting
behaviors and its life impact are often misunderstood and
incomprehensible. As a result, the human side of the
psychotic experience is often lost. Born into a privileged
family in Vietnam and pursuing her education in Switzerland, Sharon was a beautiful, humble woman with a gentle
nature. After meeting her husband abroad, she immigrated
to California and began to hear derogatory voices and show
signs of paranoia and depression. As a newly arrived
immigrant, she was diagnosed with schizophrenia. Struggling to support her in any way they could, her family's
unbreakable bond and loving perseverance were tested in
their long journey to find her care. Thomas is an active
member of his community, well-liked and frequently greeted
by those he walks by in his neighborhood. Kind and cheerful,
he enjoys Chinese food and going to church. He has also
been homeless and living on the streets of San Francisco for
the past 15 years. Originally from Ohio, he is no longer in
HERE ONE DAY: A FILM ABOUT BIPOLAR
DISORDER AND SUICIDE
Chair: Kathy Leichter
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand and reflect upon the universality and
multifaceted nature of suicide; and 2) understand the ways
in which individuals and families can overcome stigma and
bridge isolation pre- and post-vention.
SUMMARY:
When filmmaker Kathy Leichter moved back into her childhood home after her mother's suicide, she discovered a
hidden box of audiotapes. Sixteen years passed before she
10
2014 INSTITUTE ON PSYCHIATRIC SERVICES
had the courage to delve into this trove, unearthing details
that her mother had recorded about every aspect of her life
from the challenges of her marriage to a state senator, to her
son’s estrangement, to her struggles with bipolar disorder.
Here One Day is a visually arresting, emotionally candid film
about a woman coping with mental illness, her relationships
with her family, and the ripple effects of her suicide on those
she loved. Here One Day is reducing stigma and isolation,
raising awareness, linking individuals and families to
support, and helping to change mental health and suicide
prevention and postvention policy across the country. By
film’s end Leichter wanted audiences to be left with a
complex interaction of human beings. She wanted mental
illness to feel more real, as if it could happen to any of us. She
wanted suicide to feel less a sensationalized drama, for it too
happens to so many, from all ethnicities and backgrounds.
Most importantly, She wanted to portray a family, like so
many others, trying to do its best under difficult circumstances, far from torn asunder, yet fundamentally transformed.
able to: 1) understand the various types of biases minority
group members have confronted historically while; examining the societal implications of marginalization; 2) define
and identify microaggressions while recognizing the psychological costs to both the victims and; perpetrators; and 3)
appreciate the personal steps each individual can take to
redress microaggressions in mental health care.
SUMMARY:
The primary aim of this symposium is to survey the progress
that minorities in psychiatric training have made in the last
50 years. Appreciating history is imperative to shaping the
future as it helps us to avoid missteps of the past and to
honor those that paved a smoother road for us. However, it is
not enough to simply note the difference between yesterday
and today as we still have many improvements to make
within our own training programs. As such, we will also
discuss ways to take action in order to move in the right
direction and achieve our goals. The first session will feature
Dr. Donna M. Norris, co-editor of Women in Psychiatry:
Personal Perspectives (2012), and Dr. Orlando B. Lightfoot,
one of five authors of the landmark AJP article, "Problems of
Black Psychiatric Residents in White Training Institutes"
(1970). The two trailblazers will graciously share their
experiences as psychiatrists-in-training and early career
psychiatrists during a time of few minority psychiatrists. In
the second session, four APA members-in-training will share
their experiences of marginalization in residency. Of course,
no history lesson would be complete without a discussion of
the future. Dr. Ranna Parekh, co-author of Overcome
Prejudice at Work (2012), will close the session with words of
empowerment, explaining the value of being aware of
microaggressions acts that infringe upon someone's time,
energy, space and mobility and how to develop strategies,
gain perspective, and optimize one's frustration tolerance
when confronting insults, microaggressive acts, and prejudice.
OCT 31, 2014
SERVING THE SAME POPULATIONS:
COLLABORATING FOR BETTER OUTCOMES
Chair: Saul Levin, M.D., M.P.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand one’s distinct professional role within
alternative comprehensive, cooridinated care models; and 2)
identify practical collaborative/team-building strategies for
providing quality care and improving outcomes.
SUMMARY:
This forum addresses the multitude of issues concerning
how best psychiatrists and social workers can work together
in different settings and with different populations as we
adapt to new health care delivery systems and new funding
mechanisms. Specifically discussed will be integration of
health and behavioral health care, with primary care integrated into behavioral health settings or behavioral health
integrated into primary care settings; the focus on quality
and outcomes; strategies for effective team practice; the
importance of prevention and early intervention; person and
family-centered care. Additional discussion will focus on the
psychosocial issues that need to be more fully addressed in
order to reduce hospitalizations and concerns regarding the
high use of psychotropic medications in foster care and in
long term care.
HOW TO CREATE AN INTEGRATED TELEHEALTH
PSYCHIATRIC SERVICE PROGRAM FOR RURAL
MH POPULATIONS
Chairs: Michael Farnsworth, M.D., Sara Emich
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the technical, administrative, and clinical
challenges in delivering high quality, cost effective, efficient
telehealth mental health services to rural SPMI consumers in
the face of mental health provider shortages; 2) understand
current practice standards, reimbursement requirements,
and basic technical information on telehealth systems; and
3) set up a basic telehealth system to provide remote access
to patients.
SUMMARY:
Recruitment and retention of mental health practitioners
into rural practices is an enormous challenge. This workshop
details how 10 counties in South Central Minnesota
responded to the needs of their spmi consumers by creating
a technologically savvy, integrated mental health model that
combines psychiatry, mid-level practitioners and cloud
based EMR into a telehealth network which has pleased both
consumers and practitioners. Practical information on the
technical, administrative and clinical use of telehealth will be
provided.
TRAINING EXPERIENCES OF MINORITY INDIVIDUALS IN PSYCHIATRY: THEN, NOW, AND HOW TO
CREATE THE BEST FUTURE
Chairs: Andrea M. Brownridge, J.D., M.D., M.H.A., Stacia E.
Mills, M.D.
Presenters: Orlando B. Lightfoot, M.D., Donna M. Norris,
M.D., Frank Clark, M.D., Tiffani L. Bell, M.D., Cynthia
Moran, M.A., M.D., Ranna Parekh, M.D., M.P.H.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
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AMERICAN PSYCHIATRIC ASSOCIATION
NOV 01, 2014
NOV 02, 2014
INTEGRATING CARE IN UNDERSERVED
COMMUNITIES: WHAT'S POVERTY GOT TO DO
WITH IT?
THE CIVIL RIGHTS MOVEMENT AND AFRICANAMERICAN MENTAL HEALTH
Chair: Altha Stewart, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) the role physicians, especially psychiatrists, in
adviancing civil rights, and 2) understanding of how the Civil
Rights Act of 1964 impacted the health and emotional wellbeing of African Americans.
SUMMARY:
The period from 1945 to 1954 represents a uniquely negative
period for civil rights of Black Americans and severely limited
advances that supported improved health and mental health
care for Blacks. The Civil Rights Movement encompassed
social movements whose goals were to end racial segregation
and discrimination against Black Americans and to secure
legal recognition and federal protection of the citizenship
rights in the constitutional amendments adopted after the
Civil War. During the Civil Rights Movement, physicians
(including psychiatrists) and other health care workers gave
aid to civil rights workers, provided a ‘medical presence’ to
deal with the physical and psychological aftermath of the
attacks and violence, and mobilized the health professions to
get involved in the movement. Panelists will share their
personal stories and professional experiences and perspectives to illustrate the significance of the passage of the Act
then and the legacy of that impact on the mental health and
emotional well-being of African-Americans today.
Chairs: Derri Shtasel, M.D., M.P.H., Mark Viron, M.D.
Presenters: Derri Shtasel, M.D., M.P.H., Sarah MacLaurin,
N.P., Joanna D'Afflitti, M.D., M.P.H., Joseph Joyner, M.D.,
Mark Viron, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the challenges of integrating primary and
behavioral health care for patients living in poverty, includeing uniquely marginalized populations; 2) compare and contrast the challenges between community health centers and
community mental health centers in addressing care integration in impoverished communities; and 3) identify opportunities and challenges for young providers tasked with leading
change initiatives in Community Health Centers and
Community Mental Health Centers.
SUMMARY:
The benefits of integrating primary care with behavioral
health care are very promising, and different models have
been described that address weighting the primacy of
medical vs. psychiatric illness (1), structures of integration
(2) and the influence of payment reform on care redesign (3).
The roles of poverty and of the social determinants of health
add further complexity to these models, and require enhancements of accepted integration approaches (4). Both
Community Health Centers (CHC's) and Community Mental
Health Centers (CMHC's) serve patients with multiple
chronic disorders, many of whom are economically disadvantaged, socially marginalized and have problems beyond
the capacity of a simple dyadic medical transaction. In community health settings, standard collaborative care models
require socio-cultural adaptations to in order to be successful (5). Both settings face challenges in funding, infrastructure, and culture, though staff and patient characteristics
often differ. Adding yet one more degree of complexity are
patients who are "outsiders" to the "usual" socioeconomically disenfranchised group of patients seen in
community settings—immigrants and refugees. This group's
needs may warrant unique modifications to alreadyenhanced models of care integration. Early career primary
care and psychiatry providers tasked with leading change
within their organizations will present their approach to care
integration at a CHC and at a CMHC. Case vignettes will be
used to illustrate challenges and potential solutions specific
to these settings and the underserved communities with
whom they work.
1.
2.
3.
4.
5.
EXCELLENCE IN MENTAL HEALTH ACT
Chair: Joseph J. Parks, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) Understand two methods in gaining access to
prospective payments; 2) Understand the history of the
various approaches; and 3) Discuss the comparisons.
SUMMARY:
Innovation in payment methodology is a key strategy of the
Affordable Care Act. Payment methodologies play a key role
in realizing the goals of behavioral health parity, integration
between behavioral health and primary care, improved
access to care, and improved quality of care. This session will
present two methods by which Community Mental Health
Centers are gaining access to prospective payment methodology. First through the two-year demonstration project
offered in the newly passed Excellence in Mental Health Act
and second by becoming Federally Qualified Health Centers.
This session will present the history of these different
approaches, compare their differences in detail, and discuss
the impact on psychiatrists, consumers, and public payers of
behavioral healthcare. The session will begin with an
overview of the history of payments to CMHC's and FQHC's
and the current volume of services they provide. Second
presentation will cover the excellence in mental health act.
The third presentation will present the experience of C
MHC's becoming FQHC's. This will be followed by a panel
presentation by Representative Matsui-and author of the
excellence in mental health act, federal and state officials, C
MHC representative, and psychiatrist and consumer perspectives. The session will and with 30 minutes of audience
Q&A with panel discussion.
Mauer, BJ. 2006. Behavioral Health/Primary Care Integration: The
Four Quadrant Model and Evidence- Based Practices. National
Council for Community Behavioral Healthcare
Blount, Alexander. Families, Systems, & Health, Vol 21(2), 2003,
121-133.
Colleen L. Barry, Ph.D., M.P.P. Beyond Parity: Mental Health and
Substance Use Disorder Care under Payment and Delivery System
Reform in Massachusetts. Blue Cross Blue Shield of Massachusetts
Foundation, 2011.
Proser, M., and L. Cox. 2004. Health Centers' Role in Addressing the
Behavioral Health Needs of the Medically Underserved. Special
Topics Issue Brief #8. Washington, DC: National Association of
Community Health Centers, Inc
Ell K, Kayton W, Cabassa L, Xie B, Lee P. Kapetanovic S, Guterman
J. Depression and Diabetes Among Low-Income Hispanics: Design
Elements of a Socio-Culturally Adapted Collaborative Care Model
Randomized Controlled Trial. Int J Psychiatry Med. 2009; 39(2):113132.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
Lectures
OCT 30, 2014
trists can provide leadership in collaborative care programs,
and review the implementation of such evidence-based
programs in a range of different health care settings.
SMOKING AND MENTAL ILLNESS: A WAKE UP
CALL FOR PSYCHIATRISTS
Lecturer: Jill Williams, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the correlation between smoking and
mental illness; 2) understand the numerous consequences of
tobacco use on health, quality of life, employment and
community integration; and 3) understand the barriers that
prevent psychiatrists from intervening for tobacco use and
ways to increase access to care.
SUMMARY:
Thank you for your interest in our division. Our website is
full of information about our research team, educational
activities, current research projects and clinical trials. We
hope you will explore our website and find the information
provided helpful. Following the release of the U.S. Surgeon
General’s Advisory Committee Report on Smoking and
Health in 1964, tobacco use has become the basis of an ever
expanding area of clinical research. This report stated that
tobacco use is a cause of lung cancer and laryngeal cancer in
men, a probable cause of lung cancer in women and the
most important cause of chronic bronchitis. We now know
that tobacco use is the most common preventable cause of
death and that about half of the people who don't quit
smoking will die of smoking-related problems. Recent data
reveals that people with serious mental illness die, on
average, 25 years earlier than the general population. Under
the direction of Jill M. Williams, MD, the Division of Addiction Psychiatry, Rutgers Robert Wood Johnson Medical
School, is committed to tobacco and substance abuse
research, training and education.
RECENT ADVANCES IN THE GENETICS AND
GENOMICS OF AUTISM SPECTRUM DISORDERS
Lecturer: Matthew State, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) demonstrate a knowledge of the rationale for gene
discovery in autism spectrum disorders; 2) demonstrate a
knowledge of the important role of new (de novo) mutation
in the risk for neurodevelopmental disorders; 3) demonstrate
a knowledge of the similarities and differences between what
has been recently learned regarding the genetics of autism
and the genetics of schizophrenia.
SUMMARY:
It is an extraordinarily exciting time for the genetics and
translational neuroscience of autism spectrum disorders
(ASD). Advances in genomic technologies and the availability of large-scale study cohorts are leading to a rapidly
expanding list of ASD genes and risk regions. These recent
successes are presenting the field new challenges in
conceptualizing how to translate genetic data into an
actionable understanding of pathophysiology. This presentation will review recent progress in gene discovery in ASD,
focusing on the particular role of new (de novo) variation as
well as the overlap in genetic risks for a wide range of
neurodevelopmental disorders, including autism and schizophrenia. The challenges presented by the tremendous degree
of genetic heterogeneity that has been uncovered will be
considered. Finally, the implications of continued success in
gene discovery for clinical care will be considered.
COLLABORATIVE CARE: MAKING A DIFFERENCE
IN THE AGE OF ACCOUNTABLE CARE
GRIEF: DIAGNOSTIC AND TREATMENT
FORMULATION PROBLEMS
Lecturer: Jurgen Unutzer, M.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the clinical and business case for
integrated behavioral health care; 2) understand evidencebased clinical approaches to providing collaborative mental
health care; and 3) implement evidence-based collaborative
care programs in diverse health care settings.
SUMMARY:
Only about 2 in 10 adults living with a diagnosable mental
health condition will see a psychiatrist or a psychologist in
any given year. The Affordable Care Act will dramatically
increase the number of adults who will have insurance
coverage for behavioral health care, but our current delivery
system is already at capacity. Collaborative Care is an
evidence-based approach for psychiatrists to partner with
primary care providers to dramatically improve the lives of
the millions of adults who do not have access to effective
mental health specialty care today. Over 80 randomized
controlled trials have demonstrated that collaborative care is
more effective for common mental health disorders than
usual care. This presentation will review the clinical and the
business case for collaborative care, discuss how psychia-
Lecturer: Mardi Horowitz, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) demonstrate knowledge of the DSM-V diagnoses
that may suit post loss symptomatic responses; 2) demonstrate knowledge of the formulation of what is likely to
progress to resolution without treatment and what may need
facilitation to progress after a seemingly pathological
response to bereavement; and 3) demonstrate knowledge of
how therapy techniques might vary with persons who are
bereaved and with various levels of identity and relationship
functions before the loss.
SUMMARY:
Loss comes as a shock to most people, even those who have
had a period to anticipate the death of a loved one. Such
events occur in the midst of life stressors, social supports,
and pre-existing levels of personality function, as well as
possible psychiatric disorders. The clinician often has to
make an initial evaluation in a single extended session.
Diagnoses range across several categories, and an important
DSM 5 change from DSM-4 is to include bereavement as a
possible situation within diagnoses of Major Depressive
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AMERICAN PSYCHIATRIC ASSOCIATION
Disorders. This talk will cover the distinctions between
normal and pathological courses through mourning. An
emphasis on formulation beyond diagnoses will include
discussion of the necessary complexities. Level of personality
function is one of these complexities, requiring some
inference as to what is a regression under the trauma of loss,
and what may have been the person’s optimum level of
functioning before the loss. Implications for treatment by
psychotherapy assignments will be discussed.
appreciate the critical new roles for behavioral health care
services and public service community psychiatry in the
emerging health care system; and 3) be able to describe a
proactive, progressive agenda for the necessary growth and
development of public service psychiatry.
SUMMARY:
Psychiatry is in a distinct moment in history. The multiple
challenges facing our society have given impetus, contested
though it is, to the redesign of the way our nation delivers
health care. But is there room for psychiatryt? This lecture
will first describe the present circumstances and the particular predicament—the fiery bed, or perhaps couch—that
community psychiatry is in, before outlining a way forward
toward a revolutionary agenda of creative reengagement
with public service by a profession on fire. The lecture will
end with a discussion of the myriad implications of such a
profound reorientation on public policy, practice, our
profession and our underlying theories about psychiatric
challenges.
ALONE WE CAN DO SO LITTLE; TOGETHER WE
CAN DO SO MUCH: ADDRESSING GENERAL AND
SPECIAL POPULATION MENTAL HEALTH NEEDS
THROUGH INNOVATIVE COLLABORATIONS
Lecturer: Laura Roberts, M.D.
EDUCATIONAL OBJECTIVES:
At the conclusion of the session, the participant should be
familiar with: 1) epidemiological data concerning mental
health and its impact, including suicide, felt in the general
population 2) epidemiological data concerning mental
health and its differential impact, including suicide, felt in
specific subpopulations 3) several innovative academiccommunity collaborations who conduct inspired work to
improve understanding and health outcomes in relation to
very difficult mental health and well-being issues in the
community
SUMMARY:
Mental disorders and related conditions are common and
devastating for their impact, whether viewed in relation to
individual suffering or broad consequences for global health.
Special populations, such as young people, elders, minority,
and veterans, often carry greater burdens in terms of disability and premature mortality. Misunderstanding, prejudice,
societal and scientific neglect contribute to these grave
concerns. The problems are so immense that they cannot be
addressed by efforts, even very heroic efforts, undertaken in
isolation. Collaboration amongst partners who are attuned,
deeply committed, and highly innovative can make a difference in improving health of the general population and
special populations most at-risk for mental health issues and
suicide. Academic medicine is entrusted with advancing the
well-being of all people, now and in the future, through work
across five interdependent missions of advancing science,
educational excellence, clinical innovation, community engagement, and leadership and policy efforts. AcademicCommunity partnerships focused on specific health issues of
immense concern can bring about inspiring, unexpected,
and positive results. In this talk I present examples of
extraordinary partnerships to improve the well-being of
special populations, to prevent suicide, and to create greater
understanding of many of the hardest issues we face in
caring for people living with mental illness and related
conditions.
IMPLEMENTING FIRST EPISODE PSYCHOSIS
SERVICES: POLICY ISSUES
Lecturer: Howard H. Goldman, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the structure and content of firstepisode psychosis services; 2) understand the history of
policy barriers to implementing first-episode psychosis
services; and 3) understand current policy changes, includeing the Affordable Care Act, that will enhance implementtation of first-episode psychosis services.
SUMMARY:
This presentation will review the policy history of firstepisode psychosis services in the United States. The original
Community Mental Health Centers program emphasized
early interventions in mental disorders, but the treatment
technology did not live up to the promise of preventing
disability related to schizophrenia and other psychotic
disorders. The focus of the public mental health system
shifted to individuals who were already disabled and who
had the greatest impairment and functional limitation. In
addition, the system increasingly has been financed by
Medicaid. The main source of Medicaid eligibility for adults
has been through receipt of disability benefits from the
Supplemental Security Income program. As a result, firstepisode psychosis became a lower priority for services. The
rise of the recovery movement increased optimism for a
range of interventions that might be applied earlier in the
course of a psychotic disorder. New interventions have
stimulated policy changes to support implementing firstepisode services in the United States, including the Affordable Care Act with its expansion of Medicaid for nondisabled adults.
OCT 31, 2014
IS OUR BED ON FIRE OR IS IT US? COMMUNITY
PSYCHIATRY AND HEALTH CARE REDESIGN
Lecturer: Kenneth S. Thompson, M.D.
EDUCATIONAL OBJECTIVES:
At the conclusion of the session, the participant should be
able to understand: 1) understand the fundamental redesign
of health services contained in the Affordable Care Act; 2)
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
methods for taking care of themselves while continuing to be
effective in their professional roles; 4) learn more about
teaching methods that are evidence-based and effective
alternatives to traditional lectures, involving interactive and
smaller group discussion formats; and 5) consider more
active involvement in trying to prevent global warming and
other major environmental hazards and catastrophes,
recognizing that this represents a major public mental health
intervention.
SUMMARY:
A general review of what he sees as the important directions
for our profession to orient itself in order to be more effective
and constructive. This will involve bridging the hopes of the
past idealism of the community mental health movement
with the current and future transformation of the health
system. Can we be good clinical leaders and population
focused collaborators with our medical colleagues while
maintaining a vigilant recovery-oriented advocacy role in
relation to the persons in whose care we participate. More
importantly, can we do all this while maintaining a realistic
focus on whether and how we can affect the upstream
impacts (social determinants, cultural disparities, structural
competencies, environmental stability) on our patients' and
our communities' health and well-being. Is it any more
realistic for us to think that we can do this now than it was
when we began this idealistic odyssey 40-50 years ago?
CHALLENGES AND OPPORTUNITIES:
BEHAVIORAL HEALTH IN AN ERA OF HEALTH
REFORM
Lecturers: Pamela Hyde, J.D., Elinore F. McCance- Katz, M.D.,
Ph.D.
EDUCATIONAL OBJECTIVES:
At the conclusion of the session, the participant should be
able to understand: 1) the roles and functions of the Substance Abuse and Mental Health Services Administration
(SAMHSA); 2) the collaborative relationships between
SAMHSA and psychiatry; and 3) SAMHSA's role in behavioral
health and primary care integration and programs in behavioral health workforce development initiatives.
SUMMARY:
Forthcoming.
VIOLENCE AND MENTAL ILLNESS: RESEARCH,
RISK ASSESSMENT AND MHCS
Lecturer: Renee L. Binder, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the association between mental illness
and violence; 2) perform a violence risk assessment; and 3)
recognize the benefits of mental health courts.
SUMMARY:
Throughout history, people with mental illness have been
thought to be at higher risk for violence and this has led to
stigmatization and discrimination. Modern studies have
researched whether this association is valid and under what
circumstances. These studies need to be interpreted
cautiously in terms of differing definitions of violence,
differing definitions of mental illness, questions about the
reliability of sources of data and differing comparison
groups. The data shows that most persons with mental
illness are not violent and that most violent acts are not
committed by persons with a serious mental disorder.
Various factors increase or decrease the risk of violence and
these factors need to be considered when doing violence risk
assessments. Mental health courts have been established
throughout the United States as one type of intervention for
people who suffer from mental illness and have committed
crimes. Studies have shown that these courts can reduce
criminal recidivism and violence.
HEARING VOICES IN THREE CULTURES: A
COMPARISON WITH IMPLICATIONS FOR
RECOVERY
Lecturer: Tanya Luhrmann, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand that auditory hallucinations associated with psychosis often have different content and
meaning in different cultures; 2) recognize that not all
hallucinations are associated with psychosis; and 3) understand different techniques to manage auditory hallucinations associated with psychosis.
SUMMARY:
We still know very little about whether and how the auditory
hallucinations associated with serious psychotic disorder
shift across cultural boundaries. This paper presents the first
interview-based research to compare auditory hallucinations
across three different cultures. An anthropologist and several
psychiatrists interviewed twenty people in San Mateo,
California; Chennai, India; and Accra, Ghana who heard
voices and met the inclusion criteria of schizophrenia about
their experience of voices. We found that American subjects
were more likely to use diagnostic labels and to report
violent commands than subjects in Chennai and Accra. We
found that subjects in Chennai and Accra were more likely
than the Americans to report rich relationships with their
voices and less likely to describe the voices as the sign of a
violated mind. These observations suggest that the voicehearing experiences of persons with serious psychotic
disorder are shaped by local culture. These differences may
have clinical implications. The paper also presents an
account of hallucination-like events in the general
population.
DOING THE COMMUNITY WALTZ: A SAGING AND
RAGING TRIP WITH THE WALTS (I.E., WHITMAN TO
WHITE), WITH VISITS TO KELLY AND CRONKITE
ON THE WAY
Lecturer: David A. Pollack, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify several key developments in the evolution
of community/public psychiatry since the inception of the
community mental health era in the us, especially those that
are most relevant for the future; 2) recognize areas of health
care in which psychiatric practice that community/public
psychiatrists (and other behavioral health providers) can and
should be participating and leading; 3) demonstrate effective
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AMERICAN PSYCHIATRIC ASSOCIATION
NOV 01, 2014
SENSITIVE PERIODS IN BRAIN DEVELOPMENT:
UNMASKING HOW LIFE EXPERIENCE CONFERS
RISK FOR PSYCHIATRIC ILLNESS
FIREARMS AND VIOLENCE: IMPLICATIONS FOR
INDIVIDUAL AND POPULATION HEALTH
Lecturer: David A. Lewis, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the normal developmental trajectories
of cognitive functions; 2) identify the developmental changes
in brain circuits that underlie the maturation of these functions; and 3) recognize the vulnerability of these developmental trajectories to environmental events occurring
during sensitive periods.
SUMMARY:
The identification of individuals at high risk for a major
psychiatric illness, and the development of novel intervenetions that can change the course of the illness before its
debilitating clinical features emerge, are critical current
challenges in public health. These challenges are particularly
important for schizophrenia, a leading cause of years of life
lost to disability and premature mortality in developed
countries. Schizophrenia is now considered to be a neurodevelopmental disorder in which psychosis actually
represents a late, and potentially preventable, outcome of
the illness; that is, the appearance of the diagnostic clinical
features of schizophrenia (psychosis) represents not the
onset of the illness, but the downstream product of years of
pathogenic processes at work. From this perspective, the
development of effective preemptive treatments for schizophrenia (i.e., interventions that modify disease pathogenesis
in order to prevent or delay the appearance of psychosis)
requires knowledge of 1) the abnormalities in brain circuitry
that underlie the core functional disturbances of the illness,
2) when during the course of development these abnormalities in brain circuitry arise, 3) how life experiences
influence the appearance of these altered neural circuits, and
4) means to detect these abnormalities in brain circuitry
when their functional impact is still subclinical. This presentation will review the current evidence supporting the ideas
that 1) impairments in certain cognitive processes are the
core feature of schizophrenia, 2) these cognitive impairments reflect abnormalities in specific cortical circuits, and
3) these circuitry abnormalities arise during childhoodadolescence. For example, both excitatory and inhibitory
components of prefrontal cortical circuitry undergo marked
developmental changes in molecular content, structural
features and electrophysiological properties. Many of these
changes are protracted, persisting through adolescence, but
the rate and timing of the changes are distinctive to specific
circuit components. This constellation of developmental
trajectories likely provides the neural substrate for the
maturation of cognitive abilities that are dependent on
prefrontal circuitry, and also suggests the presence of
multiple developmental epochs when circuit components
may be particularly sensitive to adverse experiences, such as
use of cannabis. The implications of these findings for the
development and implementation of safe, preemptive,
disease-modifying interventions in individuals at high risk
for a clinical diagnosis of schizophrenia will be discussed.
Lecturer: Garen J. Wintemute, M.D., M.P.H.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) the epidemiology of firearm violence
in the United States and the major individual and population
risk factors for involvement in firearm violence; 2) the
principal policies governing firearms in the United States;
and 3) the effectiveness of some of the most widespread
policy- and practice-based efforts to prevent firearm
violence.
SUMMARY:
This research-based presentation will review the epidemicology of interpersonal and self-directed firearm violence in
the United States. A brief review of firearm design and
performance will be included. Particular attention will be
given to historical trends, personal and population risk
factors, firearm policies, and prevention efforts. We will take
a critical approach, identifying widespread misconceptions
about firearm violence and strengths and weaknesses in the
current body of research evidence. We will consider an
agenda for- and obstacles to-future research and prevention
efforts.
FROM COUCH TO CAMERA: THE REFLECTIONS OF
AN ACTIVIST PSYCHIATRIST
Lecturer: Dee Mosbacher, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) demonstrate knowledge of the dialectics of
activism and psychiatry; and 2) demonstrate knowledge of
the role of activism in a psychiatrist's life.
SUMMARY:
Dee Mosbacher, M.D., Ph.D., is a psychiatrist and Academy
Award-nominated documentary filmmaker. Her activist
academic career began in the 1970s when she earned a
doctorate in social psychology with a thesis that compared
the medical model of schizophrenia with the psychoanalytic
model, which was the prevailing view at that time. Subsequently, while at Baylor College of Medicine, Mosbacher was
propelled into further political action when a sign saying
"KILL THE QUEERS" was taped to the locker of a gay
classmate. She co-produced (with Joan Biren) Closets are
Health Hazards: Gay and Lesbian Physicians Come Out!
While Mosbacher served on the board of the American
Medical Student Association, this video was distributed to
medical schools throughout the United States and abroad.
During her residency at Harvard Medical School, Dr.
Mosbacher disagreed with the psychiatric establishment
over the most effective way to conceptualize and treat
schizophrenia. She advocated patient and family education
about the biological etiology of the illness, eschewing
psychodynamic concepts such as the schizophrenogenic
mother. As an out lesbian, Mosbacher also opposed the
psychoanalytic institute policy of refusing to admit LGBT
candidates. While a resident, she produced the video,
Lesbian Physicians on Practice, Patients, and Power, which
portrays lesbian physicians and medical students as
practitioners and recipients of healthcare. This video has
been distributed internationally. After moving to San
Francisco with her spouse Dr. Nanette Gartrell, Dr.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
Mosbacher worked in the public sector as Medical Director
for Mental Health in San Mateo County. In addition,
Mosbacher volunteered for organizations supporting
patients with HIV/AIDS and for clinics treating chronically
mentally ill homeless people. In 1991, Dr. Mosbacher coproduced and directed (with Frances Reid) the Academy
Award- nominated film, Straight from the Heart, a
documentary that explores relationships between straight
parents and their lesbian and gay children. Since then
Mosbacher has produced and/or directed another seven
films and one Web campaign under the auspices of Woman
Vision, a nonprofit she formed in 1993 to promote equal
treatment of all people through the use of educational
media.
THE NYU PSILOCYBIN CANCER PROJECT
Lecturer: Stephen Ross, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) the prevalence and spectrum of
psychological distress in patients with advanced or terminal
cancer; 2) the link between spirituality and psychological
distress in patients with advanced or terminal cancer; and 3)
the biological and psychosocial rationales for a novel
psychopharmacolgic-psychosocial treatment paradigm,
consisting of psilocybin-assisted psychotherapy, to treat
psychological and existential distress in patients with
advanced or terminal cancer.
SUMMARY:
Advanced or terminal cancer is associated with significant
psychological distress including and most notably depresssion, hopelessness, suicidal ideation and behaviors, generalized anxiety, existential distress, and death anxiety. There is a
known link between spiritual states and psychological
distress in patients with advanced or terminal cancer
diagnoses, whereby increased intrinsic spiritual states are
considered buffers against depression, hopelessness and a
hastened desire for death. Several spiritually and existentially-oriented psychotherapies have been developed over
the last decade to target diminished spiritual states,
provoked by a diagnosis of a grave cancer diagnosis. Also, in
the last decade there has been a renewed interest in the use
of hallucinogen treatment models within psychiatry to treat
a range of psychiatric conditions, including the constellation
of psychological distress in patients with advanced or
terminal cancer. Since 2008, the NYU Psilocybin Cancer
Project has administered a moderate single dose of
psilocybin to 30 participants in a double-blind placebocontrolled trial to explore the potential efficacy of
psilocybin-assisted psychotherapy in patients with advanced
cancer and psychosocial distress. We hypothesize that
psilocybin administration in combination with existentially
oriented psychotherapy can diminish psychological and
spiritual/existential distress in individuals with advanced
cancer. Preliminary clinical observations and an interim
analysis of data will be presented, in which a majority of
patients experienced acute and sustained reductions in
general anxiety, existential distress, and depression, as well
as increased in spiritual states and practices.
EMBRACING AND EXPANDING THE SCIENCE OF
RECOVERY
Lecturer: Lisa B. Dixon, M.D., M.P.H.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) how to recognize different definitions of recovery
and how they overlap and differ; 2) how to recognize that
shared decision making supports recovery; and 3) how to
recognize that peer delivered services support recovery.
SUMMARY:
The provision of care that is recovery oriented has become
an imperative for mental health services. However, a lack of
understanding and clarity about how to define and understand recovery has impeded progress toward the delivery of
recovery oriented care. This talk will explore different ways
to conceptualize recovery as well as the validity and unique
aspects of SAMSHA’s definition as distinct from traditional
research definitions of recovery. The talk will also consider
how the use of shared decision-making and peer-delivered
ser-vices support the new conceptualization of recovery.
POPULATION CARE MANAGEMENT BY CMHC
HEALTH HOMES
Lecture Chair: Joseph J. Parks, M.D. Lecturer: Joseph J. Parks,
M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) the Clinical Outcomes of Missouri
CMHC Health Homes; 2) the Health services Utilization
Outcomes of Missouri CMHC Health Homes; and 3) the
Financial Outcomes of Missouri CMHC Health Homes.
SUMMARY:
Missouri implemented CMHC Health Homes in January
2012. This lecture will present detailed perfomance outcomes after 2 years in operation. CMHC Health Homes were
designed to provide integrated person centered care to
persons with serious mental illness with multiple chronic
medical illness by providing data driven, care management,
care coordination, and preventive care. Missouri CMHC
health Homes have added nurse care managers and primary
care physician consultants to the traditional CMHC teams
which have been trained to facilitate and support their
clients general medical needs. Persons in Missouri CMHC
have had signification improvement in health outcomes,
reductions in hospital utilization and overall reduction in
total healthcare costs.
IMPROVING QUALITY: THE KEY TO HIGH
PERFORMING MENTAL HEALTH SYSTEMS
Lecturer: Nick Kates, M.B.B.S.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the dimensions of high quality care
and IHI´s Triple Aim and identify where their system may
be underperforming; 2) use a simple 5 step approach to
introducing improvements in their service; 3) understand
how to use the consumer's experience to assist in
redesigning services; and 4) apply the Improvement Model
and PDSA rapid cycle improvements.
SUMMARY:
Increasingly changes in mental health care systems are
driven by the desire to improve the quality, efficiency and
safety of the care provided. This workshop will introduce
participants to a series of practical tools and approaches for
understanding how their system is performing in the 6
domains of quality mental health care patient-centerdness,
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AMERICAN PSYCHIATRIC ASSOCIATION
timeliness, effectiveness, efficient, safe and equitable—and
where there are opportunities for improvement, why these
problems occur, and simple ways to introduce and sustain
needed changes. It begins by summarizing what quality care,
as defined by the National Institute of Medicine, is and
outlines two frameworks for analyzing a system. The first is
the UK's NHS Change model which looks at the 8
components of successful change in a system, beginning
with building a common purpose and identifying effective
leadership. The second is a simple 5 step approach for
analyzing a system, identifying root causes of problems and
introducing improvements. The workshop then introduces
some of the basic tools of quality improvement work that can
be used in any setting and describes how they can be used.
These tools include ways to measure team performance: an
analysis of how well core processes are working; building a
process map; the 5 Whys and the Fishbone diagram to
understand root causes; the Improvement model and rapid
cycles of change (Plan Do Study Act or PDSA cycles);
conducting a supply and demand analysis to improve access;
and using the consumer / family experience as a way of
redesigning services.
BLACKS AND AMERICAN PSYCHIATRY: AFTER
170 YEARS OF APA AND 50 YEARS OF CIVIL
RIGHTS, WHAT'S NEXT?
Lecturer: Altha Stewart, M.D.
EDUCATIONAL OBJECTIVES:
At the conclusion of the session, the participant should be
able to: 1) provide a history of the evolution of American
psychiatry beginning with the early works of the superintendents of mental institutions who founded the first
association; 2) describe the role of APA in shaping psychiatry’s involvement in addressing the difficult issue of race
and mental illness since 1844; and 3) provide a framework
for the role of psychiatry and American psychiatrists in
moving the field forward in the current racial climate and
promote a more culturally competent environment for clinical services delivery, research and training of the next
generation of psychiatrists.
SUMMARY:
It has been said that "the history of American psychiatry is
the history of the American Psychiatric Association". [1][1]
From its earliest days, psychiatry in American has struggled
with how to deal with the racism that is at the core of
relations between Blacks and Whites in this country. The
APA began as the Association of Medical Superintendents of
American Institutions for the Insane (later the American
Medico-Psychological Association). The 13 founding members, at an early organizing meeting established a committee
on ‘Asylums for Colored Persons’ which may represent the
first efforts to address the race problem in the years before
the Civil War. Since that time the history of the APA is filled
with many stories of the challenges raised, many still
unaddressed, as it relates to American psychiatry and African
Americans. Over the last 50 years the APA’s history related to
this interracial dynamic has been chronicled in many
different ways. Books, articles (in scientific and lay journals),
conferences and other modes of communication have raised
questions regarding racism as a mental illness, the continued
racial and ethnic disparities in the clinical arena, and
concerns about misdiagnosis and research outcomes that
result in inadequate and inappropriate treatment for Blacks
continues to concern many in the African American
community. This lecture will provide participants with an
understanding of how the evolution of psychiatry and
psychiatric practices in the US impacted the health and
emotional well-being of African Americans over that same
time period. The speaker will offer her perspective on how
the APA can increase involvement of African Americans in
the organization and the field and improve its relationship
with the African American community to assure that
advances in the field benefit this population.
Reference:
MAD v. BAD: LINKING MENTAL HEALTH
DISPARITIES AND PUBLIC HEALTH
CONSEQUENCES
Lecturer: William B. Lawson, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) Understand the disparities in mental health and
general health for African Americans, and other racial and
ethnic minorities; 2) Discuss the social policies and how they
exacerbate the problem; and 3) Learn to recognize the effects
of the combinations of different behaviors.
SUMMARY:
The racial disparities in mental health and general health
outcomes are well documented for African Americans and
other racial and ethnic minorities. Part of the persistence of
the problem is the failure to consider disturbing behavior in
African American males as related to mental disorders or
failure to believe that such the disorders are amenable to
compassionate treatment. Confounding under recognition
of mental disorders is the inability or unwillingness of many
in the African American community to be thought of as mad
vs. bad. Risk of arrest is valued over mental health treatment.
Social policies such as deinstitutionalization and the war on
drugs further exacerbate the disproportionately high incarceration and homeless rate. The incarceration further
contributes to the spread of such diseases as HIV and
hepatitis C into the general community. Interventions for
former inmates are limited by the under recognition of
mental and substance abuse disorders and by the
substitution of self-treatment with drugs of abuse and other
unhealthy behaviors. Failure to recognize the combination
of the therapeutic effects combined with the euphoric effects
of drugs of abuse and acceptance of bad vs. mad behavior
further contributes to treatment failure. Comprehensive
interventions at all levels of intervention are necessary to
reduce these persistent disparities that imperil the survivor
of African American males.
One Hundred Years of Psychiatry. Hall, JK (ed). Columbia University
Press, New York, NY, 1944.
The Formation of the Black Psychiatrists of America. Pierce, CM. In
Racism and Mental Health, (eds) Willie et al, pp. 525-554, University of
Pittsburgh Press.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
ance, functional capacity, brain activation, triggering
positive responses in neuroplasticity, improved real- world
functioning), and what types of concurrent interventions are
most likely to lead to real world functional gains. Other
issues of importance include how close these interventions
are to being broadly or even universally deliverable and what
standards of evidence would be required to determine
efficacy and long term effectiveness of treatments aimed at
cognition and functioning in schizophrenia.
HOW BIOMARKERS FOR PTSD WILL ADVANCE
DIAGNOSIS AND TREATMENT
Lecturer: Charles Marmar, M.D.
EDUCATIONAL OBJECTIVE & SUMMARY:
The Posttraumatic Stress Disorder (PTSD) Research Program
at The New York University Langone Medical Center is committed to improving the diagnosis and treatment of PTSD.
The program is currently studying the factors that promote
risk and coping in PTSD. The factors studied include structure of functional imaging, genetics, endocrine, metabolic
and proteomic biomarkers, and adverse health outcomes in
PTSD. It is believed that this work will advance our understanding of PTSD and lead to more accurate diagnosis and
more effective treatments. The main goals of the PTSD
Research Program are:

Improving the diagnosis and treatment of PTSD

Improving our understanding of the unique stressors
faced by law enforcement professionals and members of
the armed forces

Identifying both positive and negative ways that PTSD
sufferers deal with stress

Developing effective tools and treatments to assist
sufferers in the management of stress in order to
maximize emotional and physical health

Developing novel interventions to prevent PTSD
THE MULTIPLE TRAUMAS OF YOUTH BEHIND
BARS
Lecturer: Terry Kupers, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) the prevalence of trauma among the
juvenile population in the criminal justice system; 2) the
additional traumatic effects and lasting disability caused by
harsh conditions of confinement; and 3) the vulnerabilities
of youth in adult correctional facilities.
SUMMARY:
Youth in the criminal justice system usually suffered
multiple traumas prior to arrest. Many are survivors of
childhood physical and sexual abuse and witnessed or were
the object of violence in the home and in the community.
There were failures in school and, very often, substance
abuse. For those with known mental illness, public mental
health services were less than ideal. After being arrested they
spend time in jail, a youth facility, or prison (for example, if
they are tried as an adult). Huge inequities vis a vis class and
race mean that youth of color from the lowest socioeconomic strata are most likely to be incarcerated. In
correctional settings a large proportion are the victims of
violence or sexual abuse. Too often the inappropriate
behaviors they exhibit while confined are interpreted by
authorities as willful disobedience rather than symptoms of
their multipli-traumatized psychiatric condition. They very
often find their way into segregation or isolative confinement. There, forced idleness and isolation exacerbate their
emotional problems, but to the extent their symptoms
include acting out and rule-breaking, they are punished with
ever longer stints in segregation. In many states they are
actually placed in isolative confinement "for their own
protection." In the significant proportion of these youth who
are predisposed to serious mental illness, the isolation
causes further emotional damage. Assaults, harsh prison
conditions and isolative confinement exacerbate or trigger
psychiatric decompensations and suicide crises. The rate of
completed suicides is unacceptably high. Essentially a
vicious cycle of symptomatic behaviors, inappropriately
harsh punishments and re-traumatization evolves into a
downward spiral. Meanwhile, along with isolation there is
discontinuation of the educational and rehabilitative
programs they would need to become functional. Their
eventual prognosis, and their chances of remaining "clean
and sober" and succeeding at "going straight" in the
community after release, are greatly reduced.
LATEST DEVELOPMENTS IN THE ASSESSMENT
AND TREATMENT OF DISABILITY IN SEVERE
MENTAL ILLNESS
Lecture Chair: Philip Harvey, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) the measurement and treatment of
cognitive and functional deficits in schizophrenia; 2) what
types of outcome measures are best suited to detect changes
in cognition and functioning; and 3) what types of concurrent interventions are most likely to lead to real world
functional gains.
SUMMARY:
Impairments in cognitive functioning and functional capacity are among the major contributors to the poor functional
outcomes experienced by many people with schizophrenia.
In the recent past, there have been a number of cognitive
remediation strategies developed to improve cognition and
reduce disability in schizophrenia, with some of these
interventions having substantially greater benefits than older
efforts. This lecture will review the state of the art of the
measurement and treatment of cognitive and functional
deficits in schizophrenia. On the assessment side, it is
important to consider what types of outcome measures are
best suited to detect changes in cognition and functioning.
Although there are endorsed measures for pharmacological
interventions, would these same measures be best for use in
detection of remediation-induced change? On the treatment
side, there are several different questions to address. These
include identifying the treatment strategies that work the
best, at what level their benefits occur (cognitive perform-
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AMERICAN PSYCHIATRIC ASSOCIATION
NOV 02, 2014
SUMMARY:
Psychiatrists are often asked if the behavioral addictions,
such as shopping, food, sex, love, texting, e-mailing and
gambling, are really bona fide medical disorders or just an
exaggeration of everyday social and personal ailments. While
there is little doubt that these conditions present with
unique and poorly researched challenges in everyday clinical
practice, the overarching hallmark of addiction-the loss of
control over one's own life-seems to be quite similar for both
substances and behaviors that hijack a person's pleasure and
reward brain circuitry. Typically, psychiatrists and other
health providers rely on their experience treating substance
use disorders in order to address these emerging conditions.
There is little doubt that extreme forms of these impulsivecompulsive behaviors share a number of characteristics with
the severe forms of substance use disorders. four major
symptoms can be readily recognized in most addictions,
whether they are substance-driven, like cocaine and tobacco,
or simply behaviorally-driven, like gambling and shopping:
1. Tolerance-the need to use the substance or perform the
troublesome behavior at higher doses, or more and more
frequently, in order to achieve the same effect.
2. Withdrawal-the uncomfortable feeling (and sometimes
devastating syndrome), following abrupt discontinuation of
the substance or the behavior.
3. An obsession that seems to "eat up" the person from
within-having little interest in anything other than the
addictive agent, constantly coming back to "how am I going
to use," "how am I going to pay for it," "how am I going to
come down," and "how am I going to start the process all
over again."
4. External consequences of the addiction in terms of the
person's finances, health, interpersonal relationships, or
legal affairs. Apart from these relatively common symptoms,
some addictions have additional, unique characteristics, as
in the case of the problematic gambler who often exhibits
frantic efforts to recoup losses. On the other hand, moderate
forms of compulsivity present us with a dilemma. Most
clinicians agree that surfing the Internet for 2 hours a day is
probably OK, but 16 hours a day is not. But how about 4 or 8
hours a day? Where does one draw the line if the person has
not completely lost control of her or his life but is still
struggling? And then there are behaviors that have significant
impulsive or compulsive traits but for which we have not
quite made up our minds whether we should classify them as
addictions or not. Are there such things as work, exercise,
food, relationship, or love addictions? When it comes to the
behavioral addictions, we have a lot more work to do in
order to arrive at reliable diagnostic criteria, build useful
assessment tools, and develop effective psychosocial and
pharmacological treatments.
BIPOLAR DISORDER IN PRIMARY CARE: CLINICAL
CHARACTERISTICS AND GAPS IN QUALITY OF
CARE
Lecturer: Joseph M. Cerimele, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the importance of identifying bipolar
disorder in primary care patients; 2) describe the clinical
characteristics of patients with bipolar disorder seen in
primary care settings; and 3) discuss research directions for
improving quality of care of patients with bipolar disorder
seen in primary care.
SUMMARY:
Most patients with psychiatric illnesses present initially to
primary care settings. Over the past 20 years collaborative
care has been developed to treat populations of primary care
patients with depression and anxiety disorders, and a
substantial evidence base supports the use of collaborative
care in primary care. Real-life use of collaborative care in
large health systems has revealed that approximately 10-15%
of primary care patients referred for collaborative care
actually have bipolar disorder. A smaller evidence base exists
for how to best treat patients with bipolar disorder in
primary care. Patients with bipolar disorder present to
primary care for several reasons, including care of medical
problems which occur often in patients with bipolar illness,
care of depressive symptoms, or with symptoms related to
anxiety or substance use which are common in patients with
bipolar disorder. This presentation will focus on understanding the presentation of bipolar disorder in primary care and
describing the clinical characteristics of a large sample of
primary care patients with bipolar disorder encountered in a
statewide collaborative care system in Washington State. The
presentation will also include a discussion with the audience
regarding future directions on research related to improving
the quality of care delivered to primary care patients with
bipolar disorder.
THE BEHAVIORAL ADDICTIONS: GAMBLING AND
SEX AND SHOPPING AND SURFING AND TEXTING,
OH MY!
Lecturer: Petros Levounis, M.D., M.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the impulsivity- compulsivity spectrum
of illness; 2) contrast the psychiatric and social manifesttations of the behavioral addictions with substance use
disorders; and 3) identify promising serotonergic with dopaminergic psychopharmacological approaches to treatment.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
Symposia
OCT 30, 2014
NO. 2 - PHARMACY DASHBOARD TO ENHANCE
EVIDENCE-BASED PRACTICES
Presenter: Daina Wells, Pharm.D.
SUMMARY:
Easy access to up-to-date information on a provider’s
patients is vital to continuous improvement in clinical
practice. To address this need, we developed provider-level
mental health dashboards for specific clinical areas, e.g.,
metabolic monitoring, polypharmacy. This information is
focused on key messages for use by both administrators and
clinical team members within the Veterans Administration.
These audit and feedback tools leverage regional and
national data to produce a clinical performance dashboard
that generates current, visually-intuitive reports at the
regional, local facility, and individual patient level. Data
collection for the dashboards includes 100% sampling of
robust and complex data sets that are updated daily. These
innovative tools provide a snapshot global view of patient
panels and allow providers to assess actionable patient-level
information in order to change individual care and align with
evidence-based practice.
ENHANCING PSYCHIATRIC CARE WITH
INFORMATICS
Chair: Steven E. Lindley, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) name three ways measurement-based care using
an electronic medical record improves psychiatric care;
2)describe two smart phone applications that can be used to
improved outpatient mental health treatment outcomes; 3)
identify three advantages to patient entered data into an
electronic medical record in improving outcomes in patients
with schizophrenia; and 4)name three areas of evidencedbased psychiatric care that can be improved through
providing dashboards to providers.
SUMMARY:
An increasing array of computer and mobile device- based
tools are available to mental health patients and providers.
How to best adapt these new informatics tools into current
psychiatry practice in a manner that enhances both patient
care and clinical efficiency presents a challenge. In this
symposium, the development and implementation of four
different informatics tools within the Veterans Administration (VA) Health Care System will be described; 1) mobile
applications designed for psychoeducation and self-help for
those suffering from PTSD and other mental health
problems, 2)web-based mental health dashboards designed
to enhance evidence-based psychopharmacology and
psychotherapy, 3) innovative patient-facing kiosks used to
support implementation of timely, evidence- based services
and improve weight, employment, treatment, and outcomes,
and 4) a provider-driven software tool designed to enhance
measurement- based care within the VA. We will discuss the
lessons learned in the development and implementation of
these tools and how the information gained can inform the
disseminated of similar tools into a variety of mental health
treatment settings.
NO. 3 - PROVIDER-DRIVEN DEVELOPMENT OF
MEASUREMENT-BASED CARE SOFTWARE
Presenter: Steven E. Lindley, M.D., Ph.D.
SUMMARY:
Systematically collecting and recording assessment, treatment, and side effect data and using this data to inform
treatment decisions—measurement-based care—is essential
to excellent mental health care. Measurement-based care
improves overall quality of care and enhances efficacy and
implementation research efforts. But it is difficult to achieve
without the right tools to assist providers. Tools can be time
consuming to use, impede workflow, and don’t collect
clinically useful data. We developed software that is
integrated into a large electronic medical record system and
into the provider’s workflow. The software provides a single,
integrated system for documenting, recording and analyzing
a) clinical data, b) interventions, and c) assessments. It is
being developed with on-going input from outpatient mental
health clinicians. The overall goal is to drive the development of mental health information technology tools that
have maximum impact on the quality of patient care.
NO. 1 - MOBILE HEALTH APPLICATIONS: IMPLICATIONS
FOR THE FUTURE OF PTSD SERVICES DELIVERY
Presenter: Josef I. Ruzek, Ph.D.
SUMMARY:
Mobile applications that provide education and enable selfmanagement of PTSD symptoms are rapidly being developed and tested. More than a gimmick, these technologies
hold promise for addressing key challenges in the delivery of
effective treatments. Using as illustrations a range of smartphone apps developed by the National Center for PTSD, we
argue for the capacity of mobile health technologies to
improve evidence-based decision- making, foster outcomes
monitoring, enable clinicians to see more patients and
address a wider range of problems, reduce training needs,
empower paraprofessional care, and engage patients and
families in recovery following traumatization.
NO. 4 - USING PATIENT-FACING KIOSKS TO SUPPORT
IMPROVED CARE AT MENTAL HEALTH CLINICS
Presenter: Alexander S. Young, M.D., M.P.H.
SUMMARY:
Evidence-based services improve outcomes in schizophrenia, but many patients do not receive such services. This
gap has been perpetuated by a lack of routinely collected
data on patients' clinical status and the treatments received.
However, routine data collection can be completed by
patients themselves, when aided by information technology.
In a controlled trial, eight medical centers of the VA were
assigned to implementation or usual care for 571 patients
with schizophrenia who were overweight. Implementation
was informed by data from patient-facing kiosks, and
included clinical champions, education, social marketing,
and evidence-based quality improvement teams. Implementation resulted in patients being more likely to use weight
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AMERICAN PSYCHIATRIC ASSOCIATION
services, getting services 5 weeks sooner, and using 3 times
more visits. Mental health has been slow to adopt information technology. This is among the first studies to evaluate
implementation of automated data collection at these
clinics.
_______________________________________________________
and mortality due to OUD is a public health imperative, and
evidence-based medication therapies for OUD have been
demonstrated across studies and regional cohorts to
consistently double the rates of opioid abstinence achieved
in treatment for OUD, while medical detoxification alone
results in rapid relapse (> 80% in most studies).
ADVANCES IN ADDICTION PHARMACOTHERAPY
NO. 2 - ALCOHOL PHARMACOTHERAPY: WHAT IS THE
FIRST LINE MEDICATION?
Presenter: Steven Batki, M.D.
SUMMARY:
During the past 20 years, major advances have been made in
understanding the neurobiology of alcohol use disorder
(AUD). This increased understanding has led to discovery of
effective medications, several of which have received FDA
approval for relapse prevention. This presentation will
summarize the state of the art regarding the optimal use of
the FDA- approved medications - naltrexone, acamprosate
and disulfiram. The presentation will cover some key clinical
variables affecting treatment response such as early vs. late
onset of AUD, and abstinence versus continued alcohol use
at the start of treatment. The presentation will also discuss
the use of newer medications that show promise, such as
topiramate, baclofen, and ondansetron. New findings in the
pharmacotherapy of AUD in the presence of co-occurring
psychiatric disorders will also be covered.
Chair: Larissa Mooney, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to identify: 1) agonist, partial agonist, and antagonist
medications for the treatment of opioid disorders; 2) FDA
approved and emerging pharmacotherapies for the treatment of alcohol use disorders; and 3) FDA approved
medications for the treatment of nicotine dependence.
SUMMARY:
Substance use disorders remain a significant public health
concern, with 10% and 30% of U.S. adults meeting lifetime
criteria for drug and alcohol use disorders, respectively. The
addicted patient presents numerous dilemmas to the treating psychiatrist, not least of which is the proper selection of
the safest and most efficacious pharmacologic treatments for
substance use disorders and for some of the co-occurring
psychiatric disorders that accompany substance use. This
symposium will address emerging and evidence-based
pharmacologic treatment options for the addicted patient,
focusing on four common substance use disorders: opioids,
alcohol, stimulants, and nicotine. Attendees will gain a basic
knowledge of state-of-the-art approaches to managing these
disorders and the evidence-base for FDA approved and offlabel pharmacotherapy choices in these four clinical
domains. While there are FDA approved medication options
for the treatment of opioid, alcohol and nicotine use
disorders, there are no approved medications for cocaine
and methamphetamine dependence despite decades of
research. As a result, evidence-based behavioral treatments
are considered the first-line approach to reduce stimulant
use and facilitate abstinence. The prescription of opiate
agonist/partial agonists and antagonists hinges on balancing
benefits with potential harms and requires examination of
the limited data on direct comparison of the efficacy of the
different medications. Similarly, the evolving list of medications available for alcohol use disorder and nicotine
cessation require that the clinician have a firm grasp of the
risks, benefits, and latest data from clinical trials. Evidence
from research studies suggests that certain medications may
be useful in restoring neurotransmitter deficits caused by
stimulant use and target symptoms associated with
withdrawal, with the goal of initiating abstinence or reducing
relapse. This symposium will review the latest evidence to
guide clinical decision-making when selecting pharmacotherapy for addicted and dually diagnosed patients.
NO. 3 - MEDICATIONS UNDER DEVELOPMENT FOR
STIMULANT USE DISORDERS
Presenter: Larissa Mooney, M.D.
SUMMARY:
The use of stimulants including methamphetamine (MA)
and cocaine is associated with a broad range of psychiatric
symptoms, medical consequences, and other public health
impacts. Despite decades of research, no medications have
yet been FDA approved for the treatment of cocaine or MA
use disorder; evidence-based behavioral treatments are
considered the first-line approach to reduce stimulant use
and facilitate abstinence. Evidence from research studies
suggests that some medications may be useful in restoring
neurotransmitter deficits caused by stimulant use and target
symptoms associated with withdrawal, with the goal of
initiating abstinence or reducing relapse.
NO. 4 - PHARMACOTHERAPY FOR NICOTINE
DEPENDENCE
Presenter: Petros Levounis, M.A., M.D.
SUMMARY:
The most recent evidence of safe and effective pharmacological interventions for people who suffer from tobacco
use disorders will be reviewed. We will present best practices
for the use of food and drug administration (fda) approved
medications: bupropion, varenicline, and nicotine replacement therapies (patch, gum, inhaler, lozenges, and nasal
spray). Contraindications and major advantages and
disadvantages for each intervention will be discussed, as well
as strategies for combining pharmacological interventions,
when appropriate, for maximum efficacy. The controversy
over the reported neuropsychiatric sequelae of varenicline
and bupropion, the black box warnings, and the scientific
evidence supporting or refuting these claims will be critically
assessed. While research in the pharmacotherapy of tobacco
use disorders appears to have slowed down in recent years,
we will briefly review a few key experimental pharmacological agents, including the nicotine vaccine.
NO. 1 - MEDICATIONS FOR OPIOID USE DISORDERS:
PRACTICAL CONSIDERATIONS IN SELECTING OPIOID
AGONIST AND ANTAGONIST THERAPIES
Presenter: John A. Renner Jr., M.D.
SUMMARY:
The prevalence of opioid use disorders (OUD) has increased
10-fold over the past decade and both heroin use and illicit
prescription opioid analgesic use has increased dramatically
among youth cohorts, leading to a national epidemic of
opioid-related overdose deaths. The prevention of morbidity
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
_______________________________________________________
NO. 2 - INTRODUCTION TO SOCIAL DETERMINANTS OF
MENTAL HEALTH
Presenter: Ruth S. Shim, M.D., M.P.H.
SUMMARY:
This presentation will elucidate the concept of social deteminants of mental health and mental illness using WHO’s
definition of social determinants of health as a framework. It
will discuss the “syndemic” concept and population health,
gene-environment interactions and the ability to influence
the social determinants through policy change. It will review
the literature on health inequalities and health inequities
along socioeconomic gradients across countries and within
countries. Emphasizing the connection to social justice, this
presentation will also discuss how addressing the social
determinants of mental health is a moral imperative.
WHEN THE COMMUNITY IS YOUR PATIENT:
POLICY PRESCRIPTIONS FOR THE SOCIAL
DETERMINANTS OF MENTAL HEALTH. PART I:
SOCIAL AND INTERPERSONAL DETERMINANTS
Chairs: Michael T. Compton, M.D., M.P.H., Ruth S. Shim,
M.D., M.P.H.
Discussant: David A. Pollack, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the concept of the social determinants
of mental health; 2) list three social determinants that can be
characterized as "social" or "interpersonal" determinants of
mental health; and 3) discuss three activities that community
psychiatrists may engage in to improve mental health in
their communities by addressing social determinants.
SUMMARY:
This presentation challenges psychiatrists to consider their
responsibility in addressing policies that are damaging to the
mental health of our communities. We will focus on the
social determinants of mental health and mental illnesses,
which are defined as those factors stemming from where we
are born, grow, live, work, learn, and age that contribute to
or detract from the mental health and well-being of
individuals and communities. Although mental illnesses are
often underpinned by genetic predisposition and gene-byenvironment interactions, we will highlight the social
determinants of such disorders, which are likely modifiable
through social and policy interventions. The World Health
Organization estimates that there are more than 10 major
social determinants that affect health; this symposium will
serve to introduce mental health providers to several of these
determinants in greater depth, emphasizing the impact on
mental health and illness. After a series of presentations,
former U.S. Surgeon General Dr. David Satcher will discuss
"a policy prescription" for the various social determinants
presented. This is Part I of a two-part Symposium on the
social determinants of mental health. Part I focuses on those
social determinants of mental health that can be thought of
as social and interpersonal in nature, whereas Part II
pertains to those social determinants of mental health that
can be characterized as "environmental."
NO. 3 - POVERTY/INCOME INEQUALITY AS SOCIAL
DETERMINANTS
Presenter: Marc W. Manseau, M.D., M.P.H.
SUMMARY:
Economic factors, including both deprivation and inequality,
are important determinants of mental health and mental
illness. This presentation will highlight and address individual and area-level poverty, and the impact of the widening
gap between rich and poor in the US. Mediators and
moderators of the association between income inequality
and poor mental health will be presented. Possible policy
solutions will be discussed.
NO. 4 - SOCIAL ISOLATION AND EXCLUSION AS SOCIAL
DETERMINANTS
Presenter: Kenneth S. Thompson, M.D.
SUMMARY:
Social support and healthy social networks are known to be
good for one's physical and mental health. On the other
hand, social isolation and social exclusion are associated
with poor physical and mental health outcomes. This
presentation will review the literature on social isolation and
social exclusion as social determinants of mental health, and
will present potential solutions that can be effected at the
clinical and policy level.
NO. 5 - DISCRIMINATION/DEMOGRAPHIC INEQUALITY
AS A SOCIAL DETERMINANT
Presenter: Camara P. Jones, M.D., M.P.H., Ph.D.
SUMMARY:
Inequalities and discrimination that arise from society based
on the innate characteristics of a group (e.g., based on race,
ethnicity, or sexual orientation) are detrimental to both
physical and mental health. Furthermore, many of the social
determinants of health are in part driven by discrimination
and inequalities based on demographics. This presentation
will review the literature pertaining to discrimination and
demographic inequalities as a social determinant of mental
health, and present solutions that must be enacted at the
policy level.
_______________________________________________________
NO. 1 - ADVERSE EARLY LIFE EXPERIENCES AS SOCIAL
DETERMINANTS
Presenter: Carol Koplan, M.D.
SUMMARY:
This presentation will review of the impact of early childhood experiences upon mental health, highlighting the
“Adverse Childhood Experience” (ACE) study, childhood
trauma, foster care and separation from parents, and
consequences of perinatal depression and bullying. Recommended interventions will focus on early home visits,
prevention of child abuse, prevention and treatment of
perinatal depression, importance of the two- generation
approach, and increasing social inclusion and connectedness.
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of distress and mental illness and share strategies for
connecting ministries of churches, mosques, or synagogues
to public mental health systems of care for chronically
mentally ill patients.
AT THE INTERSECTION OF SPIRITUALITY AND
MENTAL HEALTH: PSYCHIATRISTS AND FAITH
LEADERS WORKING TOGETHER
Chair: Altha Stewart, M.D.
NO. 3 - MENTAL ILLNESS AND FAMILIES OF FAITH: HOW
CONGREGATIONS CAN RESPOND
Presenter: Susan Gregg-Schroeder
SUMMARY:
The presenter will describe her work in founding Mental
Health Ministries, an interfaith web-based ministry that
provides educational resources to help erase the stigma of
mental illness in faith communities. The presentation will
include how to help faith communities become caring
congregations for both people living with a mental illness
and those who love and care for them based on the “caring
congregations” five step model. The steps are: Education,
Commitment, Welcome, Support, and Advocacy. She will
also share her personal journey to recovery to illustrate the
model in action.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize ways for faith and psychiatric leaders to
work together more effectively to address the emotional
health needs of general public, including ministers; 2)
identify opportunities for establishing local collaboratives
with clergy in their home community; and 3) educate
psychiatrists about the important role of spirituality during
the recovery process for many people with behavioral health
conditions.
SUMMARY:
The APA, APF and Interfaith Disability Advocacy Coalition
(IDAC) convened a meeting in July 2014 of over 40 diverse
faith, psychiatric and other MH leaders to establish the MH
and Faith Community Partnership. Its aim is to create a
collaborative relationship between psychiatrists and faith
leaders to foster a dialogue between the two fields, reduce
stigma, and address the medical and spiritual dimensions of
people seeking care for their emotional health needs. The
partnership will create new resources to provide training to
spiritual leaders about mental health and substance abuse
issues, and for psychiatrists about faith and the role of faith
communities in behavioral health recovery. This symposium
will include presentations by leaders in both the faith and
psychiatric community who are currently working on
establishing the collaborative relationships needed to impact
the "health of the whole person" as described by partnership
member and mental health advocate, former Congressman
Patrick Kennedy. Speakers will address efforts to begin the
dialogue with our faith colleagues to whom many turn in
times of emotional distress, reduce stigma, and share ways to
educate each group on the role of the other in behavioral
health recovery. There will be ample time for Q&A and
interaction with participants.
NO. 4 – SPIRITUALLY-INTEGRATED TREATMENT
Presenter: John Peteet, M.D.
SUMMARY:
The presenter will describe his work at the interface between
spirituality/religion and psychiatry in clinical practice. He
will review his work on the DSM-5 research agenda related to
spiritual and religious issues in psychiatric diagnosis. He will
also provide updates on the work of the American Psychiatric
Association’s Caucus on Religion, Spirituality and Psychiatry.
NO. 5 - FAITH, SPIRITUALITY AND MENTAL HEALTH
RECOVERY
Presenter: Alan Johnson
SUMMARY:
The presenter is co-founder of the interfaith network on
mental illness (www.inmi.us) and national chair of the
United Church of Christ Mental Health Network
(www.mhjn-ucc.blogspot.com). A retired chaplain at the
Children’s Hospital in Denver, his presentation will address
the understanding of faith and spirituality as potential
resources in one’s recovery in mental health and describe his
work in providing mental health educational programs
targeted at faith communities and developing the introduction to spirituality for the mental health first aid program.
Finally, he will share his personal story, as a father of a son
who lives with a mental illness and a brother of one who
ended his life, from the perspective of an ordained clergy.
NO. 1 - THE MENTAL HEALTH AND FAITH COMMUNITY
PARTNERSHIP: PSYCHIATRISTS AND FAITH LEADERS
WORKING TOGETHER
Presenter: Meenatchi Ramani, M.D.
SUMMARY:
The presenter will briefly describe the goals and initial work
of the newly formed APA initiative, the Mental Health and
Faith Community Partnership Steering Committee. Beginning with a dialogue on opportunities for mutual
understanding and action among members of the faith and
psychiatric communities, APA/APF leadership met with
partners at AAPD/IDAC. She will discuss the short term
projects identified and the resources needed for those
projects that will highlight the intersection of Mental Health
and Faith.
NO. 2 - COMBATTING THE STIGMA OF MENTAL ILLNESS
IN THE FAITH COMMUNITY
Presenter: James Griffith, M.D.
SUMMARY:
The presenter has worked extensively in the area of
spirituality and mental health and will discuss opportunities
for engaging religious professional or groups to address the
stigma against psychiatry, psychiatric patients and mental
illness. He will also help describe how to assist religious
professionals in distinguishing between normal syndromes
NO. 6 - COLLABORATING WITH FAITH COMMUNITY
LEADERS TO HELP PHYSICIANS WITH SPIRITUAL
STRUGGLES
Presenter: James Lomax, M.D.
SUMMARY:
The presenter will discuss his work at the interface between
religion, spirituality, and healing from a psychiatric and
psychoanalytic perspective. He will describe his work at the
interface between spirituality/religion and psychiatry in
clinical practice and the work of the Institute for Spirituality
and Health. He will review his current work in the area of
helping physicians with spiritual struggles and will include a
discussion of a case that illustrates some of the issues he will
address.
_______________________________________________________
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
educate ourselves, inform ourselves, and use our positions to
help all underserved and disadvantaged groups get the best
care possible. In this symposium, we tackle one important
group, the LGBT community. By bringing more awareness
and evidence-based practice to the source of care, it is our
hope that LGBT patients will ultimately have better
psychiatric outcomes and better health overall.
OCT 31, 2014
MISTAKEN IDENTITY: IMPROVING CARE FOR
LESBIAN, GAY, BISEXUAL AND TRANSGENDER
(LGBT) PATIENTS FROM EDUCATION TO
IMPLEMENTATION
Chair: Amir Ahuja, M.D.
NO. 1 - TEACHING ABOUT CLINICAL ISSUES IN RELATION TO SEXUAL ORIENTATION IN THE ERA OF DSM-5
Presenter: Robert P. Cabaj, M.D.
SUMMARY:
Homosexuality was removed from the DSM in 1973 and Ego
Dystonic Homosexuality was removed in 1986 and there are
no categories in DSM-5 touching sexual orientation, so why
is there a need to keep teaching about clinical issues and
sexual orientation? Though there is no psychopathology in
any variation of sexual orientation, people with minority
sexual orientations do face clinical challenges that can be
related to the acceptance—or not—of that sexual orientation
either by society or by that individual. How to teach but not
imply psychopathology is an important way to help
behavioral health and primary care providers be better
equipped to provide optimal clinical care to people with
minority sexual orientations. Both content and ways of
teaching will be discussed.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) articulate the way in which to approach the issue
of LGBT mental health and inform others on this topic in a
non-judgmental, culturally-sensitive way; 2)identify and
enumerate the connections between discrimination and
minority stress and future (or concurrent) psychiatric
morbidity and mortality; 3) identify the unique concerns of
the LGBT population in regards to patterns of substance use,
unique epidemiological patterns and what works best in
treating this population; 4) synthesize the presentations to
develop a broader knowledge about origins of mental illness
in LGBT people, clinical concerns unique to this population,
and best clinical and educational practices; and 5) formulate
strategies to improve the mental health, physical health, and
care delivery in regards to LGBT people, and maximize
cultural competency within the psychiatric profession.
SUMMARY:
It has been repeatedly shown throughout the academic
literature that there are clear health disparities for the
Lesbian, Gay, Bisexual, and Transgender (LGBT) population.
Mental healthcare, and particularly psychiatry, is no different. One can see this in the way that the issue of LGBT
mental health is discussed. There are often major gaps in
knowledge for even the most well-meaning psychiatrists.
Often, this issue is discussed with inherent biases that we
cannot correct until they are brought to light. Frequently
there is a stress on psychopathology as opposed to mental
wellness, which frames the LGBT population as significant
only for lack of health. Much work can be done on improving
the way this topic is approached, taught, and conveyed in
academic settings. Another way we can see it in the way that
care is informed and researched. Too often there is an
assumption of illness inherent to a certain population
without much thought as to its origins. In a heterosexualdominant society, one can ignore the ways in which minority
stress can influence the physical and mental health of the
LGBT minority. More frequent exposure to abuse, bullying,
domestic violence, and discrimination on all levels takes its
toll on the health of this population. The way this is understood can better inform compassionate care, and can lead to
more attention and intervention at a social level to improve
patient outcomes. A final way that these health care
disparities are seen is in the delivery of care. In particular,
substance abuse care is frequently laden with judgment. This
is true for heterosexual patients, but even more so for the
LGBT minority. By understanding the roots of the substance
use patterns and behaviors of LGBT people, one can become
more adept at dealing with some unique concerns these
patients have. One can also be more efficient and have better
outcomes by fostering a sense of understanding and
inclusiveness in care. This can only happen by being
culturally competent and keeping up with trends in LGBT
culture. Why is this important? A significant portion of our
populace, and therefore of our patients, is needlessly
suffering due to a lack of being understood and properly
cared for. As psychiatrists, we have a responsibility to
NO. 2 - BIOLOGICAL EMBEDDING OF TOXIC STRESS
AND HEALTH DISPARITIES IN LGBT INDIVIDUALS
Presenter: Andres F. Sciolla, M.D.
SUMMARY:
Several medical and psychiatric health disparities have been
documented in LGBT populations. A robust predictor of
health disparities is the presence of childhood adversities,
ranging from interpersonal abuse and neglect to violence
exposure and structural disadvantage, such as low SES and
discrimination. Research has documented the staggering risk
of LGBT individuals of exposure to early life adversities, such
as childhood sexual abuse. Insufficient attention has been
paid to the clinical, research and policy implications of the
contribution of adverse childhood experiences to health
disparities in LGBT individuals. This presentation seeks to
address these knowledge and practice gaps by offering a
critical overview of the extant literature as well as hands-on,
practical suggestions for healthcare providers of LGBT
individuals. These suggestions will focus on the clinical care
of LGBT ethnic minorities affected by various syndemics,
and signal a paradigm shift for future practice.
NO. 3 - STIMULANT USE AMONG GAY MEN OVER THE
PAST 40 YEARS: FROM COCAINE TO ECSTASY, TINA,
"BATH SALTS," AND SMILES
Presenter: Petros Levounis, M.A., M.D.
SUMMARY:
The rise in stimulant use among gay and bisexual men in
urban centers over the past 20 years has resulted in a greater
understanding of the biological, psychological, and cultural
dimensions of the problem, as well as the development of
specific treatments for this population of patients. We will
review (a) the crack cocaine epidemic of the 1980s, which
seems to had affected equally gay and straight populations;
(b) the methylene-dioxy- methamphetamine rage of the
1990s; (c) the explosion of crystal methamphetamine in the
gay male circuit party scene of the 2000s; and finally (d) the
new phenomenon of the synthetic cathinones (‘bath salts”)
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AMERICAN PSYCHIATRIC ASSOCIATION
and related substances. Culturally informed individual and
group psychotherapy, based on the principles of Motivational Interviewing and frequently organized around the
MATRIX Model (a multi-faceted cognitive-behavioral
modality that includes contingency management and
addresses frequently co-occurring hypersexuality), appears
to be most effective.
_______________________________________________________
NO. 2 - UNEMPLOYMENT AND UNDER-EMPLOYMENT AS
SOCIAL DETERMINANTS
Presenter: Brian McGregor
SUMMARY:
Unemployment and under-employment are known to be
associated with poorer physical health and poorer mental
health. This is partly due to their effects on poverty/income
inequality, poor housing, food insecurity, poor access to
care, and other social determinants of health. This presentation will review the literature on unemployment and
under-employment as social determinants of mental health,
and will address how policy solutions could improve the
mental health of individuals and communities, and reduce
the risk of mental illnesses.
WHEN THE COMMUNITY IS YOUR PATIENT:
POLICY PRESCRIPTIONS FOR THE SOCIAL
DETERMINANTS OF MENTAL HEALTH. PART II:
ENVIRONMENTAL DETERMINANTS
Chairs: Michael T. Compton, M.D., M.P.H., Ruth S. Shim,
M.D., M.P.H.
Discussant: Altha Stewart, M.D.
NO. 3 - A BRIEF INTRODUCTION TO THE SOCIAL
DETERMINANTS OF MENTAL HEALTH
Presenter: Michael T. Compton, M.D., M.P.H.
SUMMARY:
This presentation will define key concepts such as social
determinants of health, health inequalities and inequities,
health disparities, and social justice. Ways of conceptualizing
the social determinants of mental health will be reviewed,
setting the stage for subsequent presentations in this
symposium.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the concept of the social determinants
of mental health; 2) list three social determinants that can be
characterized as "environmental" social determinants of
mental health; and 3) describe three ways that psychiatrists
can be involved in addressing environmental social determinants of health that affect the overall mental health of a
community or population.
SUMMARY:
This presentation challenges psychiatrists to consider their
responsibility in addressing policies that are damaging to the
mental health of our communities. This is Part II of a twopart Symposium on the social determinants of mental
health, which are defined as those factors stemming from
where we are born, grow, live, work, learn, and age that
contribute to or detract from the mental health and wellbeing of individuals and communities. Although mental
illnesses are often underpinned by genetic predisposition
and gene-by- environment interactions, we will highlight the
social determinants of such disorders, which are likely
modifiable through social and policy interventions. The
World Health Organization estimates that there are more
than 10 major social determinants that affect health; this
symposium will continue to introduce mental health
providers to several of these determinants in greater depth,
emphasizing the impact on mental health and illness. This
section pertains to those social determinants of mental
health that can be characterized as "environmental"
determinants. After a series of presentations, former
American Psychiatric Foundation President Dr. Altha
Stewart will discuss "a policy prescription" for the various
social determinants presented.
NO. 4 - LOW EDUCATION AND EDUCATIONAL
INEQUALITIES AS SOCIAL DETERMINANTS
Presenter: Rebecca A. Powers, M.D., M.P.H.
SUMMARY:
Poor education, low educational attainment, and educational inequalities lead to poorer occupational achievement,
lower income, and other social determinants of health. The
presenter will review the evidence on education-related
social determinants of mental health. Potential policy-level
solutions will be described.
NO. 5 - HOUSING INSTABILITY AND ADVERSE
FEATURES OF THE BUILT ENVIRONMENT AS SOCIAL
DETERMINANTS
Presenter: Lynn Todman, Ph.D.
SUMMARY:
The places where we live, play, work, and age have an impact
on both physical and mental health. This presentation will
review the literature on how housing and "the built
environment" impact the mental health of individuals and
communities. The importance of health impact asessments
of policies will be presented. Policy changes that would
enhance housing and improve the built environment—and
thus improve mental health and reduce the risk of mental
illnesses—will be presented.
_______________________________________________________
NO. 1 - POOR ACCESS TO CARE AS A SOCIAL
DETERMINANT
Presenter: Frederick J. P. Langheim, M.D., Ph.D.
SUMMARY:
This presentation will focus on the effects of poor access to
care, specifically addressing unequal distribution and access
to healthcare, varying quality of healthcare, and inequality of
the mental health care system compared to the general
healthcare system. The potential preventive benefits of
mental health integration into primary-care-based, publicly
funded, universal health care will be discussed.
HIV PSYCHIATRY TODAY
Chair: Lawrence M. McGlynn, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) learn approaches to diagnosis and treatment of
HIV-Associated Neurocognitive Impairment/Disorder; 2)
understand the impact of substance use and coinfection
with hepatitis C on HIV care; and 3) recognize common drug
interactions between HIV medications and psychotropic
medications.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
SUMMARY:
To successfully diagnose and treat patients with HIV/AIDS,
psychiatrists need to understand the complex biomedical
aspects of AIDS as well as patterns of HIV infection in special
patient populations. Good clinical care can frequently be
impeded by the presence of subtle cognitive impairments,
substance use disorders, or coinfection with Hepatitis C.
New medications with new side effect profiles make treating
HIV-infected persons with a psychiatric illness increasingly
complex. This session will provide the most up-to-date
information on diagnosis and treatment of cognitive disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and
syphilis, and the safest psychotropics to use with some of the
new HIV medications. The session will include a lecture
followed by an interactive question and answer period
providing participants the opportunity to discuss individual
clinical concerns.
NO. 3 - PRACTICAL HIV PSYCHOPHARMACOLOGY:
INDICATIONS, SIDE EFFECTS, AND INTERACTIONS
Presenter: Wilson Ly, Pharm.D.
SUMMARY:
To successfully diagnose and treat patients with HIV/AIDS,
psychiatrists need to understand the complex biomedical
aspects of AIDS as well as patterns of HIV infection in special
patient populations. Good clinical care can frequently be
impeded by the presence of subtle cognitive impairments,
substance use disorders, or coinfection with Hepatitis C.
New medications with new side effect profiles make treating
HIV-infected persons with a psychiatric illness increasingly
complex. This session will provide the most up-to-date
information on diagnosis and treatment of cognitive
disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and
syphilis, and the safest psychotropics to use with some of the
new HIV medications. The session will include a lecture
followed by an interactive question and answer period
providing participants the opportunity to discuss individual
clinical concerns.
_______________________________________________________
NO. 1 - HIV-ASSOCIATED NEUROCOGNITIVE
IMPAIRMENT: ASSESSMENT AND SCREENING
Presenter: Karl Goodkin, M.D., Ph.D.
SUMMARY:
To successfully diagnose and treat patients with HIV/AIDS,
psychiatrists need to understand the complex biomedical
aspects of AIDS as well as patterns of HIV infection in special
patient populations. Good clinical care can frequently be
impeded by the presence of subtle cognitive impairments,
substance use disorders, or coinfection with Hepatitis C.
New medications with new side effect profiles make treating
HIV-infected persons with a psychiatric illness increasingly
complex. This session will provide the most up-to-date
information on diagnosis and treatment of cognitive
disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and
syphilis, and the safest psychotropics to use with some of the
new HIV medications. The session will include a lecture
followed by an interactive question and answer period
providing participants the opportunity to discuss individual
clinical concerns.
INTEGRATING CARE: PSYCHIATRY AND MEDICINE
IN SERVICE TO OUR PATIENTS
Chair: Paul Summergrad, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identity evidence based models of integrated care
and the core principles associated with these models; 2)
understand the role of the psychiatrists in emerging models
of care in a reformed health care system; and 3) recognize
the major causes of medical comorbidity in patients with
serious mental illnesses and the psychiatrists' role in
improving the health status of this group who have a
shortened life expectancy.
SUMMARY:
The integration of primary health and behavioral health has
a robust evidence base and the dissemination and adoption
of this practice has progressed rapidly. The idea that bringing
together the diverse cultures of primary care and behavioral
health to better treat mental illnesses in primary care and
improve the health status of those with mental illnesses in
public mental health settings both intrigues and excites
professionals in both disciplines. In primary care settings the
development and implementation of the IMPACT and
TEAMCare models have proven that collaborative care
models, which introduce new members to the health care
team: a consultant psychiatrist and a care manager, can
improve outcomes in the treatment of mental illness, are
cost effective to implement and can reduce overall healthcare expenditures. In public mental health settings an
emerging data base shows connecting our most vulnerable
patients with serious mental illnesses to much needed
resources in primary care can lead to effective treatment of
chronic illnesses associated with cardiovascular disease.
Receiving this care can lead to the reduction in morbidity
and mortality responsible for the 25 year mortality gap. The
major stumbling blocks to the full scale dissemination of
these models include the siloed funding for mental health
and primary care dollars, same day billing of a primary care
and behavioral health visits, carved out mental health
funding, and lack of coding and reimbursement models to
pay for the collaboration and consultative portions of care
NO. 2 - MANAGEMENT CHALLENGES OF MULTIPLE
MORBIDITIES: HIV, SUBSTANCE USE, HEPATITIS C AND
SYPHILIS
Presenter: Lawrence M. McGlynn, M.D.
SUMMARY:
To successfully diagnose and treat patients with HIV/AIDS,
psychiatrists need to understand the complex biomedical
aspects of AIDS as well as patterns of HIV infection in special
patient populations. Good clinical care can frequently be
impeded by the presence of subtle cognitive impairments,
substance use disorders, or coinfection with Hepatitis C.
New medications with new side effect profiles make treating
HIV-infected persons with a psychiatric illness increasingly
complex. This session will provide the most up-to-date
information on diagnosis and treatment of cognitive
disorders, the impact of prescription drug and methamphetamine use on care, new treatments for hepatitis c and
syphilis, and the safest psychotropics to use with some of the
new HIV medications. The session will include a lecture
followed by an interactive question and answer period
providing participants the opportunity to discuss individual
clinical concerns.
27
AMERICAN PSYCHIATRIC ASSOCIATION
are some of the barriers to widespread dissemination and
implementation of these models of care. While the inseparable nature of mental health and primary care is recognized
by psychiatrists by virtue of their medical training, funding
mechanisms will have to be developed to more fully engage
them in this work. Models of funding are currently being
tested nation-wide, funded by innovation projects provided
in the Affordable Care Act, legislated changes in state
Medicaid reimburse structures, private foundations and
other resources to bridge the gap to more sustainable
funding is implemented. The value added to a healthcare
system when psychiatric and behavioral health resources are
included is well proven and healthcare teams held
accountable for outcomes, cost containment and patient
satisfaction (the "Triple Aim"), will seek our expertise to
design systems of care to meet these goals. Psychiatrists need
to be prepared for these changes to assist in well-informed
and meaningful ways. This symposium brings together
national experts in the field to discuss integrating care in
multiple settings and will provide a discussion of the
evolving role of psychiatrists to meet the needs of these new
models.
the expectation that the field of psychiatry take responsibility
for the mortality gap.
NO. 1 - INTEGRATING CARE: A GLOBAL IMPERATIVE
Presenter: Paul Summergrad, M.D.
SUMMARY:
The burden of comorbid psychiatric and general medical
disorders will grow significantly over the next two decades as
the burden of noncommunicable disease grows throughout
the world. Integrative and collaborative care models will be
essential given the relative paucity of psychiatrists in many
parts of the world. This presentation will review the changing
global burden of disease and the need for an international
focus on mental health.
LESSONS LEARNED FROM WORKING WITH
"REMOTE" PATIENTS
NO. 4 - IMPLEMENTATION OF VALUE-ADDED NONTRADITIONAL PSYCHIATRIC CARE IN THE ACO
SETTING
Presenter: Roger Kathol, M.D.
SUMMARY:
The delivery of psychiatric services will become a core part of
medical care during the next decade as the health system
tries to meet the triple aim of improving care, improving
health, and lowering cost. Psychiatrists will need to re-orient
their practices so that they deliver value-added psychiatric
care in the medical setting. This presentation will identify
specific areas of practice transformation that will maximize
the value that psychiatrist bring to their patients, to systems
in which they work, and to the health system. This will take
place in new delivery organizations called accountable care
organizations.
_______________________________________________________
NOV 01, 2014
Chairs: Richard L. Merkel Jr., M.D., Ph.D., James L. Griffith,
M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify sociocultural and other structural issues
that cause patients to be remote and that could contribute to
doctor-patient conflict or misunderstandings; 2)recognize
elements in the doctor-patient relationship that may contribute to distance and the potential for conflict or misunderstandings; and 3)acquire techniques for enhancing the
doctor-patient relationship gained from experience working
with remote patients.
SUMMARY:
Psychiatrists in general are having increased experience
working with "remote" patients. We define remote as any
structural dimensions that may cause a distance between the
patient and the psychiatrist. These include, but are not
limited to geographic, economic, and sociocultural differences that may contribute to doctor-patient conflicts and
misunderstandings. Remoteness is a relative term and to
some extent there are potential differences between all care
givers and their patients. The presenters in this symposium
have all had extensive experiences working with patients in
which there are extreme differences leading to marked
remoteness. They have learned from these experiences and
will present what they have learned that can be applied to
most all doctor-patient relationships, regardless of degree of
remoteness. The participants in this symposium have had
experience working with Nepali survivors of trauma on
location, refugees in the United States, impoverished rural
patients in Appalachia via Telepsychiatry, and patients with
fundamental religious beliefs that are opposed to psychiatry.
These experiences have enhanced their ability to work with
patients where there is less remoteness and who are more
typical of most psychiatric practices. They will present these
lessons through this symposium. This symposium is
sponsored by the Society for the Study of Psychiatry and
Culture.
NO. 2 - PSYCHIATRY IN PARTNERSHIP WITH PRIMARY
CARE
Presenter: Jurgen Unutzer, M.D., M.P.H, M.A.
SUMMARY:
Integrated Care programs in which psychiatrists support and
work closely with primary care providers to care for defined
populations of patients with common mental health and
substance use problems offer exciting new opportunities for
psychiatrists to extend their reach and help improve the
health of populations. Evidence-based integrated care programs are informed by principles of good chronic illness care
such as measurement-based practice, treatment to target,
and population-based practice in which all patients are
tracked in a registry to make sure no one falls through the
cracks. We will discuss such core principles of effective integrated care and give examples of psychiatrists working in
integrated care programs with diverse patient populations.
NO. 3 - THE ROLE OF THE PSYCHIATRIST IN
ADDRESSING HEALTH DISPARITIES IN THE SMI
POPULATION
Presenter: Lori Raney, M.D.
SUMMARY:
Significant health disparities exist for the population with
serious mental illnesses (SMI) and the role of the psychiatrist
in addressing this inequality is changing. Many of the causes
of premature mortality are preventable and psychiatrists will
need new skills in addressing these issues and taking a
population-based approach to managing patients. This
presentation will include a discussion of these new skills and
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
tions of this tool to improve task-sharing in cross-cultural,
low income settings are discussed.
NO. 1 - APPALACHIA ON MY MIND: LESSONS FROM A
REMOTE POPULATION
Presenter: Richard L. Merkel Jr., M.D., Ph.D.
SUMMARY:
After many years of doing telepsychiatry consultations to
Primary Care Practitioners in SW Virginia, working with
patients from an Appalachian cultural context, it has become
clear that skills gained in working with this remote population are important for working with all populations. The
cultural context includes high levels of poverty, structural
violence, distrust of outsiders, strict gender expectations,
and fundamental Christian beliefs. Lessons learned from
working with this population include the importance of
pride in the face of poverty, the importance of gaining
specific information about traumatic life experiences, the
importance of not assuming motivation for behaviors that
appear familiar, and the importance of appreciating the role
of religious beliefs in the doctor-patient interaction. These
will be described and discussed and examples of applications to less remote patients will be given.
NO. 4 - WHAT WORKING WITH REFUGEES CAN TEACH
ABOUT THE DOCTOR-PATIENT RELATIONSHIP
Presenter: Daniel Savin, M.D.
SUMMARY:
Twenty-two years of experience with refugees from diverse
cultures has helped the presenter improve relationships with
patients in general, teaching the importance of curiosity,
patience, and flexibility. Curiosity, necessary with different
cultural groups, can improve effectiveness with more typical
patients. Patience, needed when listening to unfamiliar
histories in a second language, can increase confidence in
obtaining important information from English speaking
patients. Flexibility is needed to adjust between an authoritative approach, helpful with a Cambodian refugee expecting medication, to a more even stance with an Iraqi refugee
requesting social service assistance. This same flexibility is
helpful in working with other patients from different cultural
backgrounds, socioeconomic status and cognitive abilities.
This presentation will illustrate how these attributes, so
essential in working with refugee populations, facilitate the
development a strong working alliance with all patients.
_______________________________________________________
NO. 2 - LESSONS LEARNED FROM TREATING PATIENTS
WHO HATE OR FEAR PSYCHIATRISTS DUE TO THEIR
RELIGIOUS OR ETHNIC IDENTITIES
Presenter: James L. Griffith, M.D.
SUMMARY:
In Emanuel Levina’s analysis of violence, a person feels
violated, often responding with counterviolence, when
continuity of self feels disrupted. Psychiatrists regularly
evaluate patients who are fearful or disdainful of Psychiatry
due to perceived threats to their religious or ethnic identities.
Such encounters are difficult yet serve as a laboratory for
learning experientially how to create clinical practices and
settings that avoid identity disruption. This presentation
illustrates how identity disruption can be avoided by: (1)
active interest in the patient’s religious or ethnic identity
before clinical intervention commences, (2) reducing
physiological arousal, (3) minimizing ambiguity and uncertainty, (4) establishing personal contact, rather than categorical contact, with the disdainful patient, which typically
shifts identity-driven fear or hatred “off-line,” enabling new,
generative conversation to begin.
THE SMOKING CESSATION LEADERSHIP CENTER
Chair: Steven A. Schroeder, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the epidemiology of tobacco use in
patients with behavioral health problems; 2) be familiar with
the tools to help these patients quit smoking; and 3) justify
the importance of smoking cessation for this population.
SUMMARY:
Smoking is the major cause of death and disability among
patients with chronic mental illness and/or substance use
disorders. Until recently, mental health professionals,
including most psychiatrists, have placed a very low priority
on helping smokers quit. Reasons for this inattention have
included the sense that smoking is a relatively trivial issue for
these patients, that patients don't want to quit, that they are
unable to quit, that quitting may worsen their underlying
mental health condition, and that making treatment settings
tobacco-free will worsen patient cooperation. But as the
evidence of the toll smoking exerts mounted--both for the
patients themselves and for those exposed to second hand
smoke-these attitudes have begun to change. In addition the
arguments for not engaging in smoking cessation have been
recently exposed as myths by researchers, especially
psychiatrists and psychologists. This session will review the
epidemiology of smoking among behavioral health patients,
including recent declines in both prevalence and numbers of
daily cigarettes smoked by those who have continued to
smoke. It will summarize work by the Smoking Cessation
Leadership Center of UCSF with SAMHSA and various health
professionals, including the American Psychiatric Nurses
Association. It will review a set of tools and practices that
psychiatrists can use to increase the probability of both quit
attempts and successful quitting. This session will conclude
with a patient diagnosed with chronic mental illness who will
describe how she was able to quit.
_______________________________________________________
NO. 3 - THE TASK SHARING ADHERENCE AND SPECIFIC
COMPETENCE RATING SCALE (TASC-R): A TOOL TO
PROMOTE THERAPIST QUALITY IN TRANSCULTURAL,
LOW-RESOURCE SETTINGS
Presenter: Brandon A. Kohrt, M.D., Ph.D.
SUMMARY:
There is a gap of 1.2 million health workers needed to
provide mental health services in low- and middle-income
countries (LMIC). Task-sharing, the involvement of nonspecialist health workers to deliver mental health services,
increasingly is being promoted to address this gap in the
mental healthcare workforce. This presentation addresses
the development of a tool to assess therapist quality in tasksharing initiatives. The tool is designed to be used with
healthcare workers who are not mental health specialists,
community health workers, and laypersons participating in
mental health and psychosocial services. The tool is
designed to facilitate selection of persons to be trained or to
be trainers, evaluation of trainees and training programs,
supervision in task-sharing initiatives, and evaluating fidelity
in research trials of task-sharing. The strengths and limita-
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AMERICAN PSYCHIATRIC ASSOCIATION
trained), working together with PCPs, empowering PCPs'
skill set and using stepped approaches to care to be efficient-all of this is geared toward reaching the many folks who
would rather see their PCP, live in rural areas, are nursing
home residents, or otherwise live in areas less populated by
psychiatric providers. Recently, a RCT of collaborative care
by telepsychiatry was positive. A current study of consultation to primary care is a RCT that compares synchronous
telepsychiatry (video) to asynchronous telepsychiatry
(formerly store-and-forward; Reference). Clinicians considering a practice with telepsychiatry or who have begun using
it can learn about the technology, models for providing care,
and the 'ins' and 'outs' of administrative issues.
PUBLIC HEALTH IMPLICATIONS OF LONG ACTING
INJECTABLE ANTIPSYCHOTIC MEDICATIONS IN
THE 21ST CENTURY
Chair: Jean-Pierre Lindenmayer, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify multiple barriers to the use of LAI
experience by physicians in today's practice settings;
2)understand LAI treatment with an oral antipsychotic in
patients with first episode psychosis with both neurocognitive and functional outcomes; and3)understand the
economic impact on health care resource use after initiation
of LAI antipsychotic medications.
SUMMARY:
Successful management of patients with chronic schizophrenia is complicated by a variety of real world factors,
including low treatment adherence, comorbid substance
abuse, unstable living conditions (e.g. homelessness), multiple hospitalizations and more recently contacts with the
criminal justice system. In particular poor treatment adherence can have direct public health implications both for
patients and society at large due to violent behaviors and
incarceration with inadequate or inexistent treatment. Longacting injectable (LAI) antipsychotic therapies provide
physicians with accurate monitoring of adherence and
deliver predictable therapeutic concentrations continuously
over several weeks and may represent better alternatives to
oral treatments as they eliminate the need for potential
conflicts over daily medication administration. However, LAI
formulations are not widely used in public psychiatry
practice even though they offer advantages with significant
public health implications.
_______________________________________________________
NO. 1 - ADMINISTRATIVE ISSUES (BILLING, LEGAL)
RELATED TO TELEPSYCHIATRY
Presenter: Nina Antoniotti, M.B.A., Ph.D., R.N.
SUMMARY:
The foundation for doing 'good' telepsychiatry parallels that
of 'good' practice. Attention to the interpersonal, clinical,
and administrative issues is a must. Two-thirds of telepsychiatric practice is similar to regular practice. There are
some dimensions, though, regarding reimbursement,
documentation and legal issues that need to be adjusted
and/or added. This presentation reviews those for the APA
member and provides resources from national organizations, other fields, and model programs to make this practice
easier. Data in this area are limited due to inadequate study
and proprietary matters, but that which is known and that
which can be applied to telepsychiatry from other clinical
settings will be reviewed.
NO. 2 - ASYNCHRONOUS TELEPSYCHIATRY IN PRIMARY
CARE
Presenter: Peter Yellowlees, M.B.B.S., M.D.
SUMMARY:
The process of asynchronous telepsychiatry will be described
including feasibility, reliability and validity testing, with a
focus on how effectively this innovation can be incorporated
in the virtual collaborative care model in primary care.
COLLABORATIVE CARE BY TELEPSYCHIATRY:
MODELS (SYNCH AND ASYNCH CARE), TRAINEE
ISSUES, INTERDISCIPLINARY ROLES, AND
BILLING/LEGAL GUIDELINES
Chairs: Donald Hilty, M.D., Peter Yellowlees, M.B.B.S., M.D.
Discussant: Donald Hilty, M.D.
NO. 3 - TRAINEES AND INTERPROFESSIONALS IN A
TELEPSYCHIATRY COLLABORATIVE
Presenter: John H. Wells II, M.D.
SUMMARY:
Telepsychiatry and collaborative care are intersecting more
often in various practice settings. Challenges arise when
interdisciplinary teams with percieved and real differences
in priorities attempt to communicate effectively and efficiently about patient care. Trainees such as psychiatry
residents present an opportunity for overcoming barriers to
interprofessional collaboration; however, though residents
and other trainees are included in collaborative care and
telepsychiatry in many programs, there is little guidance in
the literature to assist programs wishing to integrate
trainees. This presentation surveys available studies, guidelines, rules and practices involving interprofessional collaboration in telepsychiatry, and offers guidance based on
experience integrating residents, psychologists, social workers and other professionals into a primary care collaborative
with centralized care-management which heavily utilizes
telepsychiatry to reach underserved populations.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant
should be able to: 1) describe models of telepsychiatry
(including asynchronous telepsychiatry) for collaborative
care, including stepped care options; 2) understand the
application of telepsychiatry applied to primary care,
nursing homes and other settings; and 3) learn about the
'foundation' issues supporting telepsychiatry, including program development, interdisciplinary team roles and billing/
legal issues.
SUMMARY:
Telepsychiatry is effective based on many outcome studies
comparing it with in-person psychiatric care and usual care
in primary care settings (Reference). The foundation of its
effectiveness is good administrative planning for program
development, interdisciplinary team collaboration, and
attention to billing/legal considerations. The model of
collaborative care has made inroads in the provision of
mental health services in the primary care setting for
depression, anxiety/panic disorder and other disorders.
Fundamental parts of this are psychiatrists who 'get' the
primary care setting (often psychosomatic medicine
30
2014 INSTITUTE ON PSYCHIATRIC SERVICES
residing within the hearer's realm of consciousness. Therapy
consists of establishing dialogue among these beings and
establishing their goals, desires, beliefs, and intents.
Coalitions are formed among healthier voices resist
unhealthier voices. More healing voices can be imported
from the therapist. Puppets, drama, and masks are used in
both individual settings and group settings for the performance of these dialogues. Theatre can ensue. We present a
case series of individuals who had been given a psychosis
diagnosis and who engaged in these approaches and whose
voices became significantly less disturbing. Medication
doses were significantly decreased over a period of 1 to 3
years. Within this series, we made the observation that many
patients stopped reporting voice hearing to their psychiatrist, since it inevitably resulted in medication dose increases
with the result of the occurrence of unacceptable side effects
and no change in the voices. Our series of patients challenged the idea that increasing medication doses overcomes
voices. We suggest that a place exists for psychotherapeutic
techniques to fill the gap between what medication can do
and the residual suffering remaining. There may also be a
substantial number of people who hear voices and never
come to psychiatric attention. Some of these people fall into
the category of religious or spiritual experiences, some have
been raised in cultures in which hearing voices is expected
and considered normal, and others may have spontaneously
learned to manage their voices without medical intervention.
NO. 4 - DELIVERY OF PSYCHIATRIC SERVICES TO
NURSING HOME RESIDENTS USING TELEPSYCHIATRY
Presenter: Terry Rabinowitz, M.D.
SUMMARY:
Depression and other psychiatric conditions are common
among nursing home residents. These conditions are often a
cause of suffering and in addition, may adversely affect the
outcome of co-occurring non-psychiatric conditions. Despite the high rates of occurrence, many of these conditions
go undetected, untreated, or misdiagnosed, often because
psychiatrists are not available or are not interested in visiting
nursing homes—this is especially true in rural areas where
long distances between patients and potential care providers
make it difficult or impossible for patients in need to get
appropriate services. In addition, many psychiatrists are
unwilling to spend many hours on an individual consultation due to poor reimbursement rates. This talk will address
psychiatrist shortages among nursing home residents and
how a telepsychiatry approach is an acceptable, efficient,
and cost effective alternative to face-to-face care for this
vulnerable and underserved population.
_______________________________________________________
WORKING PSYCHOTHERAPEUTICALLY WITH
PEOPLE WHO HEAR VOICES: CROSS-CULTURAL
AND NARRATIVE PERSPECTIVES
Chair: Lewis Mehl-Madrona, M.D., Ph.D.
NO. 1 - HISTORICAL PERSPECTIVES ON VOICE HEARING
AND THE CURRENT INTERNATIONAL MOVEMENT
Presenter: Josephine A. Conte, D.O.
SUMMARY:
The literature of antiquity would suggest that voice hearing
was relatively more common than today. Famous figures
including Moses, Abraham, Ulysses, Achilles, and others
appear to have been hearing the voices of God or the gods.
Within indigenous cultures spirits and ancestors have
spoken to the living for as long as anyone can remember.
Ancient pictographs and other drawings are consistent with
this observation. In more contemporary times, Albert
Einstein and Thomas Edison admitted to hearing voices.
Apparently, the phenomenon is widespread and more
common than contemporary psychiatry suspects. Hearing
Voices is the one symptom for which a diagnosis of a
psychotic disorder can be made without any other signs or
symptoms. Thus, voice hearers would be reticent to share
their experiences. However, in the last 20 years, an international movement has arisen to normalize the hearing of
voices. This presentation closes with a description of that
movement and its history.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify three stances toward the ontological
status of voices, including the indigenous, the biomedical,
the psychoanalytic, and more; 2) describe three techniques
for helping clients learn how to manage their voices, thereby
suffering less and being less fearful; 3) describe three
different types of voice experiencing (persecutory, spiritual,
ancestral, guiding, etc.); 4) explain why voice hearers might
be reluctant to tell their psychiatrist/doctor about this
phenomenon; and 5) describe three limits of medication for
managing voices.
SUMMARY:
Debate exists about what voices are. An international
movement has arisen that proclaims the normalcy of voices
and is called Hearing Voices International and Intervoice.
Branches exist around the world, including Voices Victoria,
Voices Ireland, and the like. In this panel, we explore the
implications of this movement and discuss our own
experiences of working psychotherapeutically with people
who suffer from the voices they hear. We also discuss our
experience with people not identified as psychiatric patients
who hear voices they find uplifting and comforting, mostly
from indigenous cultures in North America and Australia.
We discuss the varieties of ontological perspectives on
voices, including indigenous views that grant them full
ontological status at one end of the spectrum to the biomedical view which dismisses them as random products of
diseased brains at the other end of the spectrum. We review
the neuroimaging studies of voice hearers and suggest that
these findings are most consistent with the view that voice
hearing is an ordinary phenomenon and that the problem
lies in the frontal lobes where the status and meaning of
voices are interpreted and experienced. We present an
approach that integrates the perspectives of indigenous
cultures and that of contemporary dialogical self theory in
which voices are treated as independent, ontological beings
NO. 2 - TECHNIQUES FOR WORKING WITH VOICE
HEARERS
Presenter: Barbara Mainguy, M.A., M.F.A.
SUMMARY:
In this portion of the symposium, we present the techniques
used with voice hearers. First comes dialogue with and about
the Voice. We aim for all voices to have names and to have
appearances. A voice is best associated with a visual tag.
Voices are often interviewed to learn their origins, intents,
desires, beliefs, strengths, and weaknesses. The interview is
conducted by the therapist until the client can learn to
dialogue with his or her own voices. Once voices are
identified, the question is raised as to which voices are
useful/helpful and in what contexts. Clients learn to con31
AMERICAN PSYCHIATRIC ASSOCIATION
struct dialogues with the voices. Often these dialogues begin
as performances in which puppets take on the voices.
Alternately masks or other people can be used (in a group
setting). Once voices are identified, coalitions can be formed
among healthy voices to stand up to mean or demeaning
voices. "Bad" voices are often challenged to prove that they
have power, which inevitably they don't.
nosis and monitoring of mental health symptomatology; and
4) be able to describe the results of validation studies using
these methods in different psychiatric patient populations
when compared with gold standard assessment: SCID, HAMD, CESD, and PHQ9.
SUMMARY:
Mental health measurement has been based primarily on
subjective judgment and classical test theory. Typically,
impairment level is determined by a total score, requiring
that all respondents be administered the same items. An
alternative to full scale administration is adaptive testing in
which different individuals may receive different scale items
that are targeted to their specific impairment level. This
approach to testing is referred to as computerized adaptive
testing (CAT) and is immediately applicable to mental health
measurement problems. We have developed CAT depresssion, anxiety and mania tests based on multidimensional
item response theory (IRT), well suited to mental health
constructs, that can be administered adaptively such that
each individual responds only to those items that are most
informative for assessing his/her level of severity. The shift in
paradigm is from small fixed length tests with questionable
psychometric properties to large item banks from which an
optimal small subset of items is adaptively drawn for each
individual, targeted to their level of impairment. For longitudinal studies, the previous impairment estimate is then
used as a starting point for the next adaptive test
administration, further decreasing the number of items
needed to be administered. Using decision theoretic
methods we have also developed a computerized adaptive
diagnostic (CAD) screening test for major depressive
disorder called the CAD- MDD. The CAD-MDD provides a
binary classification which maximizes association with a
clinician-based DSM-V diagnosis of MDD and estimates the
confidence in the corresponding classification. Results to
date reveal that depressive severity can be measured using
an average of only 12 items (2 minutes) from a bank of 400
items, yet maintains a correlation of r=0.95 with the 400 item
scores. Similar results are seen for anxiety and mania. Using
an average of only 4 items (< 1 minute) the CAD-MDD has
sensitivity of 0.95 and specificity of 0.87, where for the same
subjects, sensitivity for the PHQ-9 is 0.70 with similar
specificity.
NO. 3 - OUTCOMES OF PSYCHOSOCIAL APPROACHES
TO HEARING VOICES
Presenter: Lewis Mehl-Madrona, M.D., Ph.D.
SUMMARY:
In this portion of the symposium, we present outcome data
from our series of cases in Maine and Vermont, USA. Clients
participated in either individual or group sessions. Using an
intent to treat perspective, 34% of people did not achieve any
benefit. Eighty-seven percent of those people did not
complete four sessions. Their mean number completed was
2.5. Those who benefited completed a mean number of 14.1
sessions. Pre-treatment data was available for the Positive
and Negative Symptom Scales, the Clinical Global Inventory,
the Hamilton Anxiety and Depression Scales, and the
MYMOP2. Statistically significant reductions in ratings of
severity of symptoms occurred, with similar improvements
in rated quality of life. Positive symptoms lowered statistically significantly compared to baseline measurements. A
total of 40 clients began the treatment process. Other factors
besides these techniques may also be important, including
the quality of the relationship with the therapists.
NO. 4 - WHEN HEARING VOICES IS NORMAL OR
TRANSCENDENT
Presenter: Magili C. Quinn, D.O.
SUMMARY:
We complete the symposium with a discussion of those
circumstances in which hearing voices is normative or
transcendent. Within indigenous cultures, voices represent
the whispers or spirits or ancestors. All aspects of nature are
granted ontological status. Trees, animals, rocks, mountains,
rivers, all can speak. The culture expects its members to be
able to hear. A variety of spiritual traditions recognize and
celebrate those who can hear voices as being close to God or
the Greatest Being or able to receive communication from
angels or spirits. We propose that psychiatry could do well to
revise its assessment of hearing voices as always pathological. We present case studies of healthy people who report
hearing voices that are helpful to them, inspiring, and even
transformative. If hearing voices is normalized, it becomes
easier to talk about hearing voices and to work with those
who hear voices.
_______________________________________________________
NO. 1 - THE FUTURE OF PSYCHIATRIC MEASUREMENT
Presenter: Robert Gibbons, Ph.D.
SUMMARY:
The CAT-MH, is a suite of three adaptive tests for depression,
anxiety, and mania, and a diagnostic screening test for major
depressive disorder (CAD- MDD) developed as part of an
ongoing program of research funded by the NIMH. The
CAD-MDD produces a remarkably accurate screening
diagnosis of depression. The three computerized adaptive
tests produce continuous severity scores that can be used for
both assessment and monitoring. The paradigm shift
between traditional screening and assessment tools and
those associated with these tests is that they begin with a
large bank of items (1008 psychiatric symptom items) and
adaptively administer a small and statistically optimal subset
of the items (on average 12 items for each of the three CATs
and 4 items for the CAD-MDD). Nevertheless, each of the
CATs maintains a correlation of close to r=0.95 with the
entire bank of items for each test (389 depression items, 431
anxiety items, 88 bipolar items).
NOV 02, 2014
THE FUTURE OF PSYCHIATRIC MEASUREMENT
Chair: Robert Gibbons, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand item response theory and the bifactor
model as it applies to measuring psychiatric disorders; 2)
understand computerized adaptive testing as it applies to
measuring psychiatric disorders; 3) be able to discuss how
modern psychometric measurement can improve the diag32
2014 INSTITUTE ON PSYCHIATRIC SERVICES
and widely available tools for integrated assessment and
recovery planning that are already available for general
system use. First, Dr. David Mee-Lee will describe application of the newest (2013) version of the ASAM Criteria for
substance related and co-occurring disorders (Dr. Mee-Lee is
the lead developer of that document) to organizing personcentered and integrated program/service matching and
recovery planning approaches for individuals with complex
mental health and substance use needs. Second, the
symposium will discuss the newest applications of the
American Association of Community Psychiatrists Level of
Care Utilization System (LOCUS 2010) (presented by Dr. Wes
Sowers, the lead developer of that document) to the process
of integrated assessment, level of care and service matching,
and recovery planning. Finally, Dr. Kenneth Minkoff will
describe an integrated recovery planning template that has
been developed and disseminated in system wide projects
for developing recovery oriented integrated services using
the Comprehensive Continuous Integrated System of Care
(CCISC) framework in over 30 states. In order to demonstrate
the application of these tools, participants will be provided
with a complex case example, assisted to use the tools, as
well as their own clinical judgment, to determine appropriate interventions in the context of integrated recovery
planning for that case, and then participate in a discussion to
explore the current state of the art and science of assessment
and recovery planning for individuals with co-occurring
disorders and the clinical challenges that emerge in addressing their needs.
NO. 2 - VALIDATION OF COMPUTERIZED ADAPTIVE
TESTING IN A COMMUNITY
Presenter: Eric D. Achtyes, M.D., M.S.
SUMMARY:
This study sought to validate the utility of the diagnostic
screening test CAD-MDD as well as the CAT-MH suite of
tests (CAT-DI, CAT-ANX, and CAT- MANIA) for assessing
cross-cutting psychiatric symptom severity in a community
sample of adult psychiatric outpatients. One hundred fortyfive individuals, aged 18-70 years, with a range of psychiatric
diagnoses who sought access to care at Pine Rest Christian
Mental Health Services, a large, free-standing psychiatric
treatment facility located in Grand Rapids Michigan, as well
as healthy controls, were evaluated using the above
measures in addition to gold-standard diagnostic and
severity scales including the SCID for DSMIV-TR, CES-D,
PHQ9, HAM-D25 and GAF. The level of patient satisfaction
with computerized testing was also measured. Results from
this cross-sectional, prospective study will be discussed.
_______________________________________________________
INNOVATIONS IN INTEGRATED ASSESSMENT,
SERVICE MATCHING, AND RECOVERY PLANNING
FOR INDIVIDUALS WITH CO-OCCURRING
PSYCHIATRIC AND SUBSTANCE DISORDERS
Chair: Kenneth Minkoff, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the clinical principles of integrated
recovery oriented practice with individuals with cooccurring conditions that permit development of appropriately matched integrated recovery plans; 2) become
familiar with the flexible array of services that can be
provided for individuals with co-occurring disorders in an
integrated continuum of care; 3) demonstrate the ability to
use the newest versions of the ASAM Criteria (2013) and
Level of Care Utilization System (LOCUS 2010) as frameworks for assessment and person-centered recovery
planning; and 4) practice applying the principles presented,
using a recovery oriented and integrated tool as a mechanism for organizing and structuring integrated recovery
planning.
SUMMARY:
Individuals with co-occurring mental health and substance
use disorders represent a population with poorer outcomes
and higher costs in multiple domains, and often presenting
in complex crisis situations with complex needs requiring
accurate assessment to determine appropriate program and
service matching in the context of developing an integrated
person-centered recovery plan. Despite the frequency with
which this type of clinical situation occurs in adult and child
service settings, most systems do not have an organized and
systematic approach to help clinicians with the process of
integrated assessment and recovery planning throughout the
continuum of care. This symposium explores the issue of
integrated assessment and recovery planning for individuals
with psychiatric and substance use disorders, and other
complex primary health and human service needs, identifies
the clinical principles of successful multi-problem, multidimensional assessment and intervention within a recovery
oriented framework of service delivery, and then illustrates
structured approaches for application of those principles in
real world systems to real world clients. These principles are
then illustrated through a description of the most common
NO. 1 - PRINCIPLES OF INTEGRATED ASSESSMENT AND
RECOVERY PLANNING FOR INDIVIDUALS WITH COOCCURRING DISORDERS
Presenter: Kenneth Minkoff, M.D.
SUMMARY:
Dr. Minkoff will begin with a brief outline of core evidence
based principles of successful assessment and intervention
for individuals or families with co-occurring mental health
and substance use conditions, as well as other complex
needs. These principles emphasize the importance of identification of multiple primary issues or conditions, focusing in
a recovery framework on the person’s goals for a happy,
hopeful, and productive life, identification of previous
periods or efforts to make progress in the context of a
strength based longitudinal assessment, and then
application—for each issue— of stage-matched, skill-based
learning, in small steps, with big rounds of applause for each
piece of progress, to help the individual learn how to address
multiple issues over time. Within the context of these
principles, the presentation will illustrate how to apply this
approach to real world clinical situations, and to use a
simple template to document integrated stage-matched
recovery.
NO. 2 - A COMPUTER ASSISTED APPROACH TO PERSON
CENTERED PLANNING: THE LOCUS M-POWER
PLANNER
Presenter: Wesley E. Sowers, M.D.
SUMMARY:
Person centered, collaborative planning has been embraced
by transformation minded administrators and is attractive in
theory to most clinicians. A major obstacle to real life implementation has been hampered by time and productivity
constraints, and even those clinicians who are its most
fervent advocates find it difficult to develop a highly individ33
AMERICAN PSYCHIATRIC ASSOCIATION
ualized plan with the full involvement of the service user.
LOCUS is a needs assessment tool which provides a
dimensional quantified profile of client needs to assist
service intensity decisions. Using this same profile
developed in conjunction with the service user, the LOCUS
M-POWER Planner translates the identified areas of need
into a treatment plan format, allowing both suggested menu
seletions and customized inputs to the plan. Working with
the client in front of the computer facilitates the plans
development while enhancing the therapeutic relationship.
The M-POWER planner will be described and its utility will
be discussed.
times the general population), mental illness (twice the
general population), and somatic health issues that contributes to poor treatment adherence, and health risks for the
general public. This symposium will address how the
comorbidity of mental and substance abuse disorder impact
the risk for HIV/AIDS and potential treatment approaches.
Dr. Lawson will provide an overview and discuss the
problem of comorbid mental disorders and their treatment
in opiate abusing African Americans at risk for HIV/AIDs. Dr.
Smith will discuss the impact of the triple whammy in the
African American community supplemented with video clips
to identify treatment needs. Dr. Nwulia will discuss the
impact of mood disorders on HIV/AIDS and strategies for
recognizing depressive disorders in this population. Dr.
Springer will show the impact of HIV positive released
inmates on the community and provide evidence that
treatment of substance use disorders improves HIV
treatment outcomes and prevents the development of new
cases.
NO. 3 - USING ASAM CRITERIA'S MULTIDIMENSIONAL
ASSESSMENT TO DEVELOP PERSON-CENTERED
RECOVERY PLANS
Presenter: David Mee-Lee, M.D.
SUMMARY:
This presentation will improve participant’s knowledge in
providing focused, targeted, individualized behavioral health
treatment. It will provide the opportunity to practice assessment and priority identification, and translate that into a
workable, accountable treatment plan that promotes
recovery. Reference will be made to The ASAM Criteria
assessment dimensions to help organize assessment and
treatment data.
_______________________________________________________
NO. 1 - IMPACT OF HIV ACCOMPANIED BY SUBSTANCE
ABUSE AND MENTAL ILLNESS IN THE AFRO- AMERICAN
COMMUNITY
Presenter: David Smith, M.D.
SUMMARY:
In working with HIV infected patients for fourteen years at
an HIV specialty clinic, I have seen numerous Afro-American
patients with the “triple whammy.” There are well-established prejudices within the Afro-American community
against mental illness and among males, including the
phenomenon of nondisclosure of sexual preference, frequently referred to as “down low.” Of further relevance is the
explosion of methamphetamine and opiate dependence
which often results in misdiagnosing mental health
disorders. With the help of videotaped interviews I will
illustrate effective interventions in this population. The role
of the psychiatrist and mental health team in the HIV setting
can eliminate barriers to effective HIV care and prevent
morbidity and death from the virus. Discussion of stigma ,
disclosure , recovery ,spirituality and appropriate usage of
medications for mentally ill patients are all key to effectively
treating all three conditions.
TREATING THE TRIPLE WHAMMY: SUBSTANCE
ABUSE, MENTAL HEALTH AND HIV/AIDS
Chair: William B. Lawson, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) appreciate how mental health and/or substance
abuse complicate prevention and treatment of HIV; 2)
understand how under-diagnosis of mental disorders especially in minorities contribute to a continuing AIDS epidemic; 3) develop strategies for distinguishing the symptoms of
AIDs from major depression and how best to treat the
comorbid depression; and4) recognize the impact of substance abuse the spread of AIDS.
SUMMARY:
Drug abuse disorders commonly co-occur with other mental
disorders. People addicted to drugs are roughly twice as
likely to suffer from mood and anxiety disorders, and vice
versa. Moreover substance abuse and other mental disorder
are each risk factors for HIV/AIDS. Often all three can cooccur together, contributing to the HIV/AIDS epidemic, and
poor treatment adherence. This triple whammy is especially
problematic for certain populations. African Americans and
other ethnic minorities are less likely to have mental and
substance abuse disorders recognized and treated which
may contribute to their greater likelihood of contracting
HIV/AIDS and to have a poorer outcome. The war on drugs
and deinstitutionalization created a "perfect storm" in which
the correctional system saw an increase in nonviolent
offenders with complicated treatment needs, increased risk
for HIV/AIDS, hepatitis, and social and health concerns for
the public after the offender is release. Those involved in the
justice system have increased rates of substance abuse (four
NO. 2 - COMORBID MOOD AND SUBSTANCE ABUSE
DISORDERS IN AFRICAN AMERICANS UNDER COURT
SUPERVISION
Presenter: William B. Lawson, M.D., Ph.D.
SUMMARY:
Mental and substance abuse disorders are independent risk
factors for HIV. Mood and substance abuse disorders are also
common in correctional systems. This population is especially at high risk of acquiring HIV/AIDS and spreading the
disease to the community. Moreover African Americans are
overrepresented in the correctional system and this triple
whammy may explain the increasing rates of HIV/AIDS. For
this reason we examined the incidence of mood disorders in
a population of African American opiate users. More than
half had major depression or bipolar disorder and only half
were receiving evidence based psychotropic medications.
Improved access to care of this high risk population is
essential to reducing the toll of HIV/AIDS in the African
American community.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
NO. 4 - MENTAL ILLNESS NEGATIVELY IMPACTS HIV
TREATMENT OUTCOMES AMONG HIV+ CRIMINAL
JUSTICE POPULATIONS
Presenter: Sandra A. Springer, M.D.
SUMMARY:
One in 100 adults in the United States are incarcerated, with
one in 31 under community supervision in parole or probation. In the incarcerated population, HIV and psychiatric
disorders (PDs) are concentrated and syndemic, with each
negatively impacting the outcome of treatment and prevention efforts. Axis I PDs and SUDs are concentrated among
prisoners within the correctional system (CS) with 2x and 9x
(65% vs. 9%) prevalence, respectively; similarly, the prevalence of people living with HIV (PLH) is 3x greater than the
general population. CS-involved PLH have higher rates of
PDs than those without HIV, and PDs are higher among this
population compared to the community. Dr. Springer will
present findings from her NIH-funded research of HIV+
prisoners and the effect of PD on post-release HIV outcomes
and need for better pre-release psychiatric screening to
improve adequate transition to the community.
NO. 3 - MAJOR DEPRESSIVE DISORDER COMORBIDITY
IN INNER CITY AFRICAN AMERICANS
Presenter: Evaristus Nwulia, M.D., M.H.S.
SUMMARY:
Objective: To improve our understanding of salient community-specific factors associated with Major Depressive
Disorder (MDD) comorbidity in HIV, we conducted a
retrospective review of medical records in an inner-city
community clinic of predominantly low-income African
American (AA) patients. Method: A cross-sectional study of
158 AA HIV-infected individuals screened for MDD. Result:
The prevalence of past year MDD was 38% and 49% of the
population had a lifetime history of trauma. Individuals with
MDD had significantly (P<0.05) higher prevalence of heavy
drinking, abuse of prescription drugs, adjustment disorder,
PTSD, anxiety and baseline CD4 <350 cells/mm3. MDD was
inversely associated (P<0.005) with history of contact with a
spiritual advisor. However, item response analysis revealed
that stress complaints and somatic features provided the
best discrimination for severity of depression, as well as
substance use and HIV prognosis in this population.
Workshops
OCT 30, 2014
and classifying complex patients and planning their care. It
was developed and standardized in Europe by the multinational INTERMED foundation, with one of the presenters
as a member. Multiple studies have confirmed its face
validity and reliability as a clinimetric tool. We will further
discuss the development of a briefer self-assessment version
of the IM-CAG, the IM-SA, now being validated in a multinational study. The American center for this study is the
University of California, San Francisco "360 Positive Care"
HIV clinic with the workshop presenters as principle
investigators. We will describe this study in some detail, with
contributions by the primary investigator for the entire
project, Silvia Ferrari MD, University of Modena & Reggio
Emilia, Modena, Italy. Additional resources have been
developed for work with this patient population including a
published instruction manual and training program, and a
separate textbook authored by the presenters of this workshop describing the analogous MPCP method*. Case: The
following is a representative example of a complex case.
Martin was referred for psychiatric care after a serious
automobile accident while he was intoxicated. His wife had
recently left him due to his alcoholism and erratic behavior,
in part associated with an ADHD diagnosis. His job as high
school teacher was in jeopardy. Medically, his diabetes was
neglected and often out of control. He was inconsistent
about cooperating with physicians or adhering to advice
from family members. His psychiatrist accepted the role of
MPCP, organizing a treatment team that included among
others a psychologist (psychometric testing and CBT), an
addiction treatment program, and a primary care physician.
Conclusions: Two novel methods for identifying and treating
clinical complexity, in part created by the workshop presenters, will be described and illustrated.
CLASSIFYING, SELECTING, AND MANAGING
CLINICAL COMPLEXITY
Chairs: Steven Frankel, M.D., James A. Bourgeois, M.D., O.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) define and characterize "clinical complexity;" 2)
understand the health systems challenge and costs of highly
complex patients; 3) be conversant with the INTERMEDCAG system (IM-CAG) for identifying and classifying clinical
complexity, and its use in identifying cases with a high
degree of clinical complexity; 4) understand the rationale for
using the Medical-Psychiatric Coordinating Physician
(MPCP) model for the treatment of highly complex cases;
and 5) contrast the previous selection to the choice of a case
manager for treating cases with minimal or moderate
complexity.
SUMMARY:
Background: 5% of patients with systemic medical and/or
psychiatric disorders account for 50% of all health service
use. Most have one or more chronic medical illnesses and
2/3rds psychiatric disorders including substance use
comorbidity. These are "complex patients" (Kathol 2009),
their case management typically exaggerated by psychosocial and health systems factors. Objective: Our focus is the
identification and management of clinical complexity
associated with co-morbid systemic medical-psychiatric
disorders. Treatments for this group require multidiscciplinary teams headed by a physician for the most
problematic, high complexity cases (the MPCP method*) or a
non-physician case manager for low to medium complexity
patients. Method, Proposed Presentation: We will illustrate
the use of the INTERMED-Complexity Assessment Grid
method (IM-CAG), a clinical and research tool for identifying
*Frankel, S., Bourgeois, J. and Erdberg, E., Comprehensive Care for Complex Patients: The Medical-Psychiatric Coordinating Physician Model,
Cambridge University Press, 2013
35
AMERICAN PSYCHIATRIC ASSOCIATION
has shown that 1 in 3 African American and 1 in 6 Hispanic
American boys can expect to be incarcerated in their
lifetime. Even though there are more boys being incarcerated, the number of girls of color is rapidly growing as
well. This epidemic trend is further endangering the youth of
America and is disproportionately shaping American society
and dismantling our social construct. The practice of
removing children of color out of the education system and
society, minimizing the educational level and ability to work,
thus greatly hampers the child upwards mobility and
decreases opportunity. In this talk, we hope to give an
understanding of the gravity of current school policies that
disproportionately affect African Americans, such as zero
tolerance policies, in school and out of school suspension,
special education, unequal sentencing for juvenile crimes
and trying children as adults. We will discuss strategies that
work to avert the crises and how to implement them in our
communities.
THE GREAT MIMICKERS: COMMON AND RARE
MEDICAL CONDITIONS WITH PSYCHIATRIC
PRESENTATIONS
Chair: Kimberly Nordstrom, J.D., M.D.
Presenters: Michael Wilson, M.D., Ph.D., Kimberly
Nordstrom, J.D., M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize medically compromised patients; 2)
differentiate psychiatric symptoms from psychiatric disorders; 3) identify common medical illnesses that have
psychiatric symptoms; 4) recognize when to consult internal
medicine or emergency medicine colleagues; and 5) learn
basic treatments of common mimickers—medical illnesses
with psychiatric symptoms.
SUMMARY:
There are a number of general medical conditions and
medical emergencies that have prominent psychiatric
symptoms. When being triaged, patients may be referred for
psychiatric care rather than general medical care. In fact,
psychiatrists may be the first to encounter the medicallycompromised patient. It is important for psychiatrists to be
able to readily identify common mimickers and to understand overlapping symptoms for conditions that are more
rare. This workshop will review basic treatments for all
illnesses covered but the primary focus of the workshop will
be on identification and role in consultation. Similarities in
illnesses or conditions will be discussed through case
presentations. Conditions that will be reviewed include
hyper- and hypothyroid, temporal lobe seizures, encephalopathy, cardiac disease, severe pain from underlying issue,
delirium, acute intermittent porphyria, and others.
INTEGRATING OSTEOPATHIC MANUAL MEDICINE
INTO THE CARE OF PEOPLE WITH PSYCHIATRIC
DIAGNOSES
Chairs: Lewis Mehl-Madrona, M.D., Ph.D., Magili C. Quinn,
D.O.
Presenters: Josephine A. Conte, D.O., Barbara Mainguy, M.A.,
M.F.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the benefits of integrating physical,
manual medicine techniques for psychiatric patients,
including increased relaxation, decreased pain; improvement in sleep, anxiety, and agitation; 2) list three effects of
manual medicine, including limbic deactivation, reduction
in sympathetic tone, and modification of the hypothalamicpituitary axis; 3) list three techniques used in osteopathic
manual medicine; 4) list three contraindications to the use of
osteopathic manual medicine; and 5) describe three
common patient responses to including osteopathic manual
medicine in their care and three reasons some patients give
for rejecting these techniques.
SUMMARY:
Psychiatry and medicine have come to operate relatively
separate from each other. Psychiatrists do not examine or
care for the physical body, though many family physicians
provide both medical and psychiatric care for their patients.
We present a history for the development of this practice,
tracing its origins through psychoanalysis and a sense of the
body as taboo to practitioners of the soul. We ground this in
Western philosophy, particularly that of St. Augustine.
Indigenous cultures do not share these views, nor do
contemporary Asian cultures in which mental health care
includes acupuncture, tuina massage, chi gong movements,
and more. We present our experience in combining psychiatric care with osteopathic manual medicine and psychological care (narrative CBT and DBT, mindfulness, energy
psychology). A case series was developed of geriatric patients
for whom osteopathic techniques were associated with
reduction in anxiety, improvement in sleep, and avoidance
of medication. In another case study, with non-geriatric
patients with psychiatric diagnoses, energy medicine
techniques, coupled with yoga breathing, and basic t'ai chi
were associated with reduction in number of crises over
baseline, as well as reduction in emergency visits, and
hospitalizations. Lower levels of anxiety and higher quality
of life was reported. In a third case series, osteopathic
THE CHILD TO PRISON PIPELINE: AFRICANAMERICAN AND AT-RISK CHILDREN FUELING THE
PRISON INDUSTRIAL COMPLEX
Chairs: Napoleon B. Higgins Jr., M.D., Ulrick Vieux, D.O., M.S.
Presenters: Ericka L. Goodwin, M.D., Carl Bell, M.D.,
Kenneth Rogers, M.D., Kimberly A. Gordon, M.D., Aaron
Clark, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the trend of mass incarceration in American and look closely at how juveniles funneled into the
prison starting at young age; 2) identify at-risk populations
for juvenile incarceration including persons of color, the
poor and those who have involvement in legal and state
systems from an early age; 3) identify how the epidemic
trend of incarceration children is effecting American society
as a whole when you limit a child's education, income
potential and damage self- esteem and upward mobility at
an early age; 4) understand the effects of zero-tolerance
policies and suspensions directly impacts a child's
development and increase the likelihood of a life of further
punishment and incarceration; and 5) develop strategies and
initiatives that have worked to decrease juvenile incarceration and collateral harm to the populations that have been
effected by these policies.
SUMMARY:
Nationally, there has been a trend of mass incarceration of
persons in America and specifically of African-American
descent, persons of color, those who are a part of at-risk and
impoverished populations. This trend of mass incarceration
36
2014 INSTITUTE ON PSYCHIATRIC SERVICES
upwards of 90 Personalized Recovery Oriented Services
(PROS) Programs deliver recovery oriented treatment and
rehabilitation services to individuals with severe mental
illness (SMI). PROS Programs were designed as more
evidence-based and individualized alternatives to Continuing Day Treatment Programs, as well as more financially
sustainable and integrated alternatives to psychosocial
clubhouses and vocational programs in New York State.
They deliver customized, coordinated services in a variety of
settings through the use of Individualized Recovery Plans
and a flexible Medicaid reimbursement scheme. However,
despite these widening possibilities, the role of the psychiatrist in PROS Programs remains narrowly focused on
psychiatric evaluation and medication management. In this
workshop, we will describe barriers to increased psychiatrist
involvements and integration, and propose additional ways
in which psychiatrists can be utilized in such settings. Topics
will include patient engagement and evaluation, staff education and consultation, and community outreach and
advocacy. There will be a particular focus on both the
integration of physical and behavioral health services and on
risk management and assessment. We will also explore how
organizations and systems can better support the psychiatrists' expanded role, and an agency-level medical director
will speak to the logistical and financial challenges of
broadening psychiatrists' responsibilities in a large, nonprofit organization. Through these presentations, we will
provide a forum for participants to discuss their experiences
and ideas about the role of the psychiatrist in recovery
oriented programs.
techniques were associated with reduction in chronic pain.
We report on the high presence of chronic pain among
patients with psychiatric diagnoses and the relatively high
use of opiates for analgesia in this population. Engagement
of the physical body in the dialogue appears to reduce both
pain and opiate use.
OPTIMIZING THE DOC TO DOC: MANAGED CARE
PEER REVIEWERS REVEAL WHAT CLINICIANS
CAN DO AND HAVE A RIGHT TO EXPECT FROM
INSURANCE COMPANIES
Chairs: Stuart L. Lustig, M.D., M.P.H., Alvin R. Blank, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand inpatient and residential clinical
practice from the vantage point of a peer reviewer; 2) be able
to work with managed care peer reviewers to optimize more
effective clinical care, during both initial reviews and
appeals; and 3) learn what can and should be reasonably
expected from managed care companies in terms of their
commitments to the peer review process.
SUMMARY:
Inpatient clinicians must translate patients' acute care into
meaningful dialogues with managed care peer reviewers.
This workshop helps clinicians, especially those working in
inpatient and residential facilities, to be more successful
when engaging in peer reviews so the process does not feel
adversarial. Through presentations, case examples, role
plays, and discussion, managed care medical directors
suggest strategies for the peer review process to optimize
patient care, particularly when longer lengths of stay may be
justifiable. Beyond a general familiarity with "level of care
guidelines," attending clinicians are advised to focus on
immediate acuity along with specific life events that
immediately impact the patient's wellbeing. A clear diagnosis with a relevant treatment plan, salient updates and
strategies for preventing readmission help to explain the
rationale for additional time in treatment. By contrast, timebased treatments, dispositional issues, or a patient's lack of
acceptance or effective use of treatment are likely to be
viewed by peer reviewers as harder to justify. The presenters
also describe what clinicians have a right to expect from
insurance companies during peer reviews.
RISK MANAGEMENT AND LIABILITY
CONSIDERATIONS IN THE INTEGRATED CARE
SETTING
Chair: Kristen Lambert, Esq., M.S.W.
Presenter: D. Anton Bland, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify risk management and liability issues when
providing consultations in the integrated practice setting; 2)
recognize the relationships and potential liability issues
arising between the psychiatrist and other medical/nonmedical providers within the integrated care practice setting;
3) examine common claims against psychiatrists in the
integrated care setting; and 4) identify risk reduction
strategies.
SUMMARY:
Increasingly, patients needing psychiatric care are being
created in integrated care practice settings. Numerous
integrated practice models have recently emerged, all
requiring collaboration among multiple medical and nonmedical mental health providers. Depending upon the
integrated care practice model utilized, the role of the
psychiatrist may differ from that found in a traditional
psychiatric treatment setting. Specifically, when working in
these practice settings, the psychiatrist may encounter novel
liability issues when supervising mid-level practitioners or
when asked to provide consultations on a formal or informal
basis. This 1.5 hour workshop will outline some of the risk
management and liability issues that psychiatrists must
understand and consider when working in the integrated
care setting and case examples will be used to further
demonstrate types of patient care situations involving an
increased liability exposure for the psychiatrist. Risk
DETERMINING THE ROLE OF THE PSYCHIATRIST
IN RECOVERY ORIENTED PROGRAMS
Chair: Karen Rice, M.D.
Presenters: Karen Rice, M.D., Marc W. Manseau, M.D.,
M.P.H., Paula G. Panzer, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify ways in which psychiatrists can broaden
their roles in recovery oriented programs; 2) identify ways for
psychiatrists to manage risk and enhance physical health
services in recovery settings; and 3) recognize how organizations and systems can better support an expanded role for
psychiatrists in recovery oriented programs.
SUMMARY:
Though recovery-oriented and psychosocial rehabilitation
programs are becoming increasingly prevalent, the optimal
role of the psychiatrist in such programs remains to be
determined. One example is in New York State, where
37
AMERICAN PSYCHIATRIC ASSOCIATION
call for a unique network of collaborative specialists,
including psychologists, social workers, and peer- specialists,
as well as the patients themselves and their families.
Community psychiatry reflects the integration of our
profession with society, placing it within a broader social
context involving the legal and educational systems along
with the social safety net. Recently, the affordable care act
has provided new opportunities for community psychiatry
by providing funding mechanisms for increased healthcare.
In addition, new technological advancements offer a variety
of ways to communicate with both our patients and
colleagues, including telepsychiatry, other forms of telephonic or internet-based contact with patients and other
clinicians, and team-based care such as assertive community
treatment (2). The community psychiatry path reflects the
larger changes in our society and culture. Historically,
mental illness has moved from asylums and long- term
institutions to prisons, jails and the streets. Despite the many
successes of modern psychiatry, based on work in the
community, neuroscience, new technologies, psychopharmacology and evidence-based therapy, community
psychiatry continues to face an "external" stigma amongst
the general population, as well as an "internal" stigma,
coming from other medical specialties who may not view
psychiatry as a "real science", and even from our colleagues
within the private sector. A significant challenge for
community psychiatry is to educate others on the vital
impact of this work. Prior successes in community psychiatry
have led to significant growth in mental health services,
leading to an increase in related professions such as
psychology and social work. However, the growth in the nonpsychiatric sphere has changed the role of the psychiatrist in
patient treatment and within the mental healthcare team(3).
Often, a psychiatrist is viewed as a "consultant" expected to
provide "a magic pill" and little else. The professional
satisfaction of a psychiatrist depends on our patients' overall
success in treatment and recovery, of which pharmacological
treatment is only a single component. The role of a
community psychiatrist should be to provide leadership and
coordination across multiple recovery-oriented services and
resources designed to address the various interrelated needs
of the patient. By embracing this larger role, community
psychiatry has the potential to make a significant impact
toward overall improvements in mental health in our
society.
reduction strategies will be identified to help lessen these
liability exposures.
THE BRIDGE: CAPTURING SUICIDE IN FRONT AND
BEHIND THE HORRIFYING SCENES
Chairs: Petros Levounis, M.A., M.D., Rashi Aggarwal, M.D.
Presenters: Sonal Batra, M.D., Michelle Benitez, M.D., Erin
Zerbo, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize early signs and symptoms of suicidality;
2) identify common transference and countertransference
dynamics in working with suicidal patients; and 3) discuss
the influence of the media, culture, and society on suicide.
SUMMARY:
The Bridge is a documentary film (2007, 93 minutes) about
suicide from San Francisco's Golden Gate Bridge, the most
popular suicide destination in the world. Director Eric Steel
placed two cameras at the foot of the bridge and filmed most
of the 24 suicides that occurred during the 12 months of
2004. The film includes comments from friends, family, and
witnesses of the suicide, as well as a powerful interview with
a survivor of the jump. The makers of "The Bridge" have also
produced a featurette, The Making of The Bridge, which
details the reactions of the camera crew to the suicides-and
their efforts to prevent them. In this media workshop, we
explore the psychiatric aspects of suicide, especially as it
relates to the therapist. The film and the featurette help us
take a look at the reality of suffering, in front and behind the
camera respectively. In a similar way, the therapist struggles
both with the patient's feelings of despair and with her or his
own. In this workshop, we will discuss transference and
counter-transference in working with suicidal patients; the
interface of addiction, impulsivity, and self-harm; personality traits and behaviors that predict suicide and type of
suicide; and the impact of suicide to the family. We will also
address the portrayal of suicide in the mass media, the
complex influence of cultural dynamics on the suicidal
patient, and the recommendations of the American Society
of Suicide Prevention. The workshop is open to all
psychiatrists who would like to explore suicide from
psychiatric and cultural perspectives but is particularly
targeted towards members in training and early career
psychiatrists.
PSYCHIATRISTS AS LEADERS: MAXIMIZING
INTERPERSONAL EFFECTIVENESS
COMMUNITY PSYCHIATRY: PRACTICING IN THE
PUBLIC SECTOR IN THE AFFORDABLE CARE ACT
ERA
Chairs: Patrick S. Runnels, M.D., Serena Y. Volpp, M.D.,
M.P.H.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe and understand work styles in the four
quadrants; 2) describe strategies for improving engagement
individuals in each of the four quadrants; 3) apply these
concepts to real situations in their current work environments; and 4) describe the benefits of broader leadership
training as put forth in public and community psychiatry
fellowship.
SUMMARY:
With the passage and implementation of the Affordable Care
Act over the past several years, the burden to our systems of
mental health care is likely to grow, increasing the demand
for capable and innovative leaders. Consequently, many
Chair: Ksenia Nawrocki, M.D.
Presenters: Robert P. Cabaj, M.D., Roderick Shaner, M.D.,
Michael Krelstein, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand the challenges and rewards of the
profession; 2) understand manpower and leadership under
the Affordable Care Act; and 3) understand new solutions in
light of the reforms.
SUMMARY:
Community psychiatry is designed to address population
based needs, providing a network of support services that are
recovery-oriented and evidence-based (1). The basic components of our specialty “biological, psychological and social“
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
current practitioners are likely to be offered leadership
opportunities in the coming years. Yet, clinicians are offered
almost no formal leadership training and many individuals
who are promoted to leadership positions struggle as a
result. Public and Community Fellowships are among the
only training programs in the country that offer intensive
formal leadership training, but few people have any sense of
what that training is like. Here, we will focus on one area of
leadership to better demonstrate the overall value of fellowship. One of the keys to leadership is managing others with
styles different than one's own, whether it be "managing up"
to a supervisor or boss, managing across, or managing down.
Styles can be broken down into four quadrants, based on
one's level of assertiveness and responsiveness. The
presenters will demonstrate in vivo how this concept is
taught to the fellows in their programs and offer attendees
the opportunity to discuss their own leadership problems in
order to demonstrate this set of concepts.
around the world. The early reports have been very
encouraging, with decreased need for restraints at these
centers, accompanied by less assaults, reduced staff injuries,
and improved patient satisfaction scores. This workshop will
bring together leaders of hospital systems who have
successfully implemented the BETA guidelines with excellent
results. The program will begin with a concise review of the
BETA recommendations, with extra emphasis on de-escalation techniques, the centerpiece of the BETA approach.
Following will be brief reports of different hospital experiences, along with the barriers encountered and positive
outcomes, with a focus on how the attendees might be able
to implement the BETA guidelines at their own facilities.
There will be ample opportunity for audience questions and
panel discussion.
OCT 31, 2014
Chair: Steve Koh, M.D., M.B.A., M.P.H.
Presenters: Alfredo Aguirre, Helen Thomson
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to learn about: 1) some of the issues related to
individuals with serious mental illness who are resistant to
treatment; 2) development, impact and outcome of California’s Laura’s Law; 3) different model of outreach called InHome Outreach Team; and 4) current outcomes of In-Home
Outreach Team model.
SUMMARY:
Despite best efforts by mental health providers, family
members, advocates and peers, some individuals with
mental illness are resistant to receiving treatment of any
kind. Small segment of them can potentially cause harm to
themselves and/or to others while suffering from untreated
mental illness. To try to give treatment to these individuals,
in 2002, California passed Assembly Bill 1421 or Laura's Law
(1). This is an assisted outpatient treatment that is court
ordered. It is similar to New York's Kendra's Law (2). The law
can only be utilized in counties that choose to do so. With
recent publicity surrounding unfortunate, violent events
related to individuals with mental illness, there is much
interest in reviewing and considering the enactment of
Laura's Law in the California counties. The Law carries with
it some controversy and financial cost to the counties. In
terms of effectiveness, there are conflicting studies that show
marked improvement in outcome versus no significant
changes (3, 4, 5). In San Diego, California, another model is
being tried called In-Home Outreach Team (IHOT). This
model utilizes significant outreach and engagement with
treatment resistant individuals without relying on court
orders. San Diego County is in process of evaluating the
effectiveness of IHOT as it may compare to enactment of
Laura's Law. The workshop will give historical overview,
structure, procedures and current status of Laura's Law. It
will give a presentation on IHOT and compare it to Laura's
Law.
ENGAGING TREATMENT RESISTANT MENTAL
HEALTH POPULATION: CALIFORNIA'S LAURA'S
LAW AND IN-HOME OUTREACH TEAM
REDUCING RESTRAINTS USE WHILE ALSO
LOWERING ASSAULTS AND INJURIES: SUCCESS
STORIES FROM PROJECT BETA
Chairs: Daryl K. Knox, M.D., Scott Zeller, M.D.
Presenters: Janet Richmond, M.S.W., Kimberly Nordstrom,
J.D., M.D., Jon S. Berlin, M.D., Leslie Zun, M.B.A., M.D., John
S. Rozel, M.D., Margaret Balfour, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe how modern evidence-based best practices in the evaluation and treatment of agitation include a
combination of de- escalation techniques, medications, and
medical/psychiatric examinations; 2) identify how proper
evaluation and treatment of acute agitation can result in
dramatically reduced restraints use, while also decreasing
untoward outcomes such as assaults and injuries; and 3)
recognize the ways that proper evaluation and treatment of
acute agitation can be successfully implemented across a
wide variety of practice settings.
SUMMARY:
Acute agitation is encountered millions of times annually in
emergency departments and psychiatric units across the
USA. But despite attempts by the Joint Commission and
Centers for Medicare and Medicaid to encourage less coercive measures, the most common intervention for this
condition has been a process best termed "restrain and
sedate." Seeking a better approach, in 2012 the American
Association for Emergency Psychiatry culminated 18 months
of work with the publication of "Project BETA: Best Practices
in the Evaluation and Treatment of Agitation," as a six-article
special section in the Western Journal of Emergency
Medicine. Project BETA combined over forty experts into five
different workgroups, involving not only psychiatrists and
emergency medicine physicians, but patient's rights advocates, administrators, therapists and nurses as well. Project
BETA's free, open-access recommendations were different
than any previous guidelines about agitation, in that they
examined all aspects of the disease state, including triage,
medical evaluation, psychiatric evaluation, de-escalation,
psychopharmacology, and use and avoidance of restraints
and because they also included the patient's perspective in
what should be 'best practices'. Since the publication, the
guidelines have been adopted by scores of medical centers
1) California Assembly Bill number 1421, http://leginfo.ca.gov/pub/0102/bill/asm/ab_1401-1450/ab_1421_bill_20020928_chaptered.html
2) New York State, Office of Mental Health, Final Report on the Status of
Assisted Outpatient Treatment, http://www.omh.ny.gov/omhweb/
kendra_web/final report/
3) Swartz, Swanson, Steadman, Robbins, Monahan, "New York State
Assisted Outpatient Treatment Program Evaluation,"
http://www.macarthur.virginia.edu/aot_finalreport. pdf
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AMERICAN PSYCHIATRIC ASSOCIATION
trained in narrative principles in terms of outcome and cost
savings; 3) describe a narrative process used to facilitate
making meaning at the end of life; 4) list three principles of
narrative ethics; and 5) list three beneficial health effects of
having meaning and purpose in one's later years.
SUMMARY:
The symposium explores narrative psychiatry within geriatrics. We explore the power of the physician to influence
outcome with the stories he or she tells and how some of
these stories can have a nocebo effect (negative), while
others can stimulate a healing response (placebo). The
stories that we tell our patients matter for they prepare
patients for what to expect, which plays a powerful role in
medical outcomes. We provide examples from our clinical
practice: a woman with vascular dementia who can co-write
poetry and be joyful, a recently bereaved patient who chose
to sit in silence for 10 minutes with his doctor and felt the
benefit, a patient supported by text messages whilst going
through some dark hours. We address how narrative
approaches can increase a sense of meaning and pride in
one's life at the end of life and how this has positive medical
outcomes. We present a technique useful for increasing the
sense of meaning in looking back over one's life. Narrative
Psychiatry is emerging within psychiatry. It represents an
understanding that story underlies most, if not all, human
activities. Story has a neuroscience basis in that it represents
the template in which memory is stored. It is produced by
the default mode of the brain, which has also been termed
the storymaking circuitry. Within psychiatry, it results in
explanatory pluralism, the idea that multiple stories exist to
explain any phenomenon and that all can be true. The story
that matters most is the one the patient believes to be true.
Illness narratives represent the stories that patients tell to
explain their suffering. Healing narratives represent the
stories that patients (and doctors) tell about what can relieve
their suffering. Stories are important because their telling
reinforces the beliefs that they support. The more often a
story is told, through Hebbsian learning, the stronger its
supporting synaptic connections become. This is the basis of
neuroplasticity. We report on a collaborative project in
which training clinic staff in narrative competence resulted
in a statistically significantly reduced frequency of visits for
patients who came often to a general practice in England
(collaborative work with Dr. Venetia Young). For elders, an
important story is the end of life story that makes sense of all
we have done. When this story communicates meaning and
purpose the end of life is more positive than when that story
consists of regrets and recriminations. We present a method
for moving the end of life story from bitterness toward
meaning. We explore narrative ideas for end of life ethics and
explore how these ideas are those already in use in
indigenous cultures.
4) Kisely, Campbell, Preston: Compulsory community and involuntary
outpatient treatment for people with severe mental disorders, Cochran
Database of Systemic Reviews 2011, Issue 2.
5) Burns, Rugkasa, Molodynski, Dawson, Yeeles, Vazquez-Montes,
Voysey, Sinclair, Priebe: Community treatment orders for patients with
psychosis (OCTET): a randomized controlled trial, The Lancet, 381(
9878):1627-1633, 11 May 2013.
ADDRESSING DISPARITIES IN AMERICAN INDIAN
MENTAL HEALTH
Chairs: Debanjana Bhattacharya, M.D., M.P.H., Thomas
Salter, M.D.
Presenters: Peter Warhol, M.D., Daniel Dickerson, D.O.,
M.P.H., Thomas Salter, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the historical and sociopolitical context
of American Indian/Alaska Native (AI/AN) healthcare and
social determinants of AI/AN mental health; 2) recognize the
prevalence of various psychiatric and substance use disorders in AI/AN communities and disparities in provision of
specialty psychiatric care for these communities; 3) perform
a cultural assessment of an AI/AN patient using a DSM-5
based cultural formulation interview; 4) treat AI/AN patients
with mental health or substance use disorders using
culturally-based treatment models; and 5) implement
methods for reducing disparities in American Indian
communities.
SUMMARY:
American Indians and Alaska Natives (AI/AN) bear witness to
some of the most pronounced social and health inequities of
any racial/ethnic population in the United States. The Substance Abuse and Mental Health Services Administration
concludes the rate of serious mental illness in the AI/AN
population is twice that of any other race or ethnicity. The
United States Surgeon General attributes high rates of
homelessness, incarceration, alcohol and drug abuse, stress,
and trauma as principal causes of mental illness in the AI/AN
population. The reasons for these inequities can be traced
back to the unique historical interactions that Native peoples
have had with those they encountered more than 500 years
ago, and especially their interactions with the U.S. Federal
Government over the past 200 years. During this workshop,
the history and sociopolitical context of AI/AN healthcare
will be explored and social determinants of AI/AN mental
health will be discussed. Disparities in provision of specialty
psychiatric care will be examined. Cultural formulation and
overall cultural assessment of an AI/AN patient will be
reviewed, in addition to culturally based treatment options
that can be implemented to improve clinical efficacy. The
workshop will conclude with a discussion of ways that
individuals can advocate for improvements in the psychiatric care for AI/AN communities in their geographic regions.
MOC PART IV - PERFORMANCE IN PRACTICE:
MAKING IT WORK IN YOUR PRACTICE
NARRATIVE PSYCHIATRY IN GERIATRICS
Chairs: Farifteh Duffy, Ph.D., William Narrow, M.D., MPH
Presenter: Laura J. Fochtmann, M.D., Larry Faulkner, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand MOC-PART IV Performance in Practice requirements for practice assessment; 2) acquire practical skills to apply to practice assessment and improvement
initiatives in their practice; and 3) assist clinicians to prepare
Chair: Lewis Mehl-Madrona, M.D., Ph.D.
Presenter: Magili C. Quinn, D.O., Barbara Mainguy, M.A.,
M.F.A.,Lewis Mehl-Madrona, M.D., Ph.D., Josephine A. Conte,
D.O.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) define narrative psychiatry and list three
principles that differ from conventional psychiatry; 2)
describe what happens when all members of a practice are
40
2014 INSTITUTE ON PSYCHIATRIC SERVICES
for Maintenance of Certification (MOC) Part IV practice
assessment requirements.
SUMMARY:
A major challenge for clinicians is the need to maintain
expertise in the face of an ever-expanding evidence base.
Traditional didactic approaches to education show limited
success in changing practice and clinical practice guidelines
can be hard to apply at the level of an individual patient or
an organization. Consequently, there is still a substantial gap
between recommended evidence-based practices and actual
clinical care (IOM, 2001). To speed the adoption of evidencebased care, the American Board of Medical Specialties and
the American Board of Psychiatry and Neurology now
require ongoing assessment of practice (Maintenance of
Certification Part IV), which will be in full effect by 2017. In
response, the American Psychiatric Association has developed a number of clinical Performance in Practice (PIP)
units that are derived from the most recent practice
guidelines. Every three years, a psychiatrist must complete
one of these clinical PIP units, which consist of three stages:
STAGE A consists of a baseline retrospective chart review of
at least 5 patients in a specified category; delivered care is
then compared to "published best practices, practice guidelines or peer-based standards" as outlined in each PIP
clinical module STAGE B: design and implementation of a
clinical practice improvement plan STAGE C: subsequent remeasurement via a second chart review of 5 patients in the
same category within 2 years of fulfilling Stage A. The PIP
clinical modules translate conceptual information from
practice guidelines into practical steps, providing an active
learning experience that supports integration of evidencebased best practices into clinical care. In addition to
reviewing the three PIP stages, this workshop will provide
opportunity for questions and review examples aimed at
helping clinicians prepare for Maintenance of Certification
(MOC) Part IV practice assessment requirements. Successful
implementation of PIP modules in clinical practice could
change the way in which new scientific information is
disseminated and adopted by clinicians. This, in turn, could
have substantial quality improvement benefits, lessening the
current gap between evidence-based best practice and
actual care.
cataracts with quetiapine, ocular dystonias with high
potency neuroleptics, closed angle glaucoma with topirimate). People with serious mental illness also have ocular
problems indirectly related to psychiatric illness and
medication (e.g. diabetic retinopathy, cataracts related to
cigarette smoking). Despite increasing focus on integrated
care and awareness of the fact that serious mental illness
have foreshortened life expectancies and greater medical
comorbidity than their peers without mental illness, little
attention has been given to eye care and ocular disease in
people with serious mental illness. Because eye problems
contribute to functional and occupational disability and
poorer quality of life; it is imperative increase the awareness
of mental health providers regarding ocular problems in
people with severe and chronic mental illnesses. Further,
given that a majority of eye problems can be treated more
readily at the early stage, we propose that visual acuity
should be regularly assessed and periodically tested during
office and community visits. This workshop will begin with a
brief review of the literature and description of some clinical
examples of people with serious mental illness and eye
problems. Then the anatomy of the eye, the normal changes
of the aging eye and diagnosis of common eye problems will
be discussed. Some screening tools for visual problems will
be introduced. And we will address approaches to educating
mental health consumers about their eyes. During the latter
portion of the workshop the panel and audience will share
clinical experiences and explore ways to further improve on
eye care in people with serious and persistent mental illness.
ASK THE EXPERT: HIV CLINICAL CASE
MANAGEMENT
Chairs: Lawrence M. McGlynn, M.D., Karl Goodkin, M.D.,
Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) discuss the clinical impact of HIV in the brain; 2)
review medical diagnoses that present with psychiatric
characteristics; 3) share basic treatment strategies.
SUMMARY:
This workshop is designed for practicing clinicians who
diagnose, treat or manage patients with, or at risk for, HIV
and AIDS. We invite you to bring your case challenges and
present them for discussion and recommendation. This is an
interactive learning opportunity for attendees to present
their clinical cases for discussion with experts in the field of
HIV psychiatry. Faculty will encourage group participation to
complement the exchange of ideas. Attendees may wish to
attend the morning HIV update symposium to provide a
foundation for discussion.
ADDRESSING OPTHALMOLOGIC ISSUES IN
PEOPLE WITH SERIOUS MENTAL ILLNESS IN A
COMMUNITY PSYCHIATRY SETTING
Chairs: Ann L. Hackman, M.D., Xian Zhang, M.D., Ph.D.
Presenter: Deborah M. Brooks, A.B., M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify ophthalmologic issues significant to
people with serious mental illness including medication and
disease related pathology as well as common changes with
aging; 2) implement simple screening for eye problems into
community psychiatric practice and provide basic education
for community mental health consumers regarding their
eyes; and 3) demonstrate an understanding of opthalmologic
concerns in people with serious mental illness which require
prompt attention and referral.
SUMMARY:
Working in community psychiatry in an urban setting, we
have observed that there are multiple associations between
ocular disease and serious mental illness. A variety of psychiatric medications cause or contribute to eye pathology (e.g.
CARE OF THE TRANSITIONING TRANSGENDER
PATIENT: A MULTIDISCIPLINARY OVERVIEW
Chair: Dan H. Karasic, M.D.
Presenters: Madeline B. Deutsch, M.D., Maurice Garcia, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand principles of mental health assessment and care of the transitioning transgender patient,
including use of WPATH SOC 7 and DSM 5; 2) understand
issues in in the care of the transitioning patient with cooccurring psychiatric illness; 3) appreciate issues in the use
of hormone therapy in the transitioning transgender patient;
41
AMERICAN PSYCHIATRIC ASSOCIATION
recent conflicts in Iraq and Afghanistan, but the program
serves veterans, from all eras, who struggle with issues
related to (PTSD) and substance use disorders (SUD). In
seeking new models for the provision of community based
outpatient services, where capacity of the system and
providers is challenged to meet the need, the program's
clinical services are run by two Certified Peer Specialists
(CPS)—paraprofessional veterans, who have a lived experience with similar mental health disorders, and are now
successfully engaged in recovery from those disorders. Their
position requires specific training, certification and ongoing
supervision by licensed mental health professionals.
Program leadership and direction came from the Menlo Park
Division campus of this healthcare system, which is located
more than 100 miles from where the clinical services are
provided. We conclude by drawing from the broader
literature and highlight key requirements for the successful
future implementation of peers into the treatment of adults
living with PTSD. The session will end with suggestions for
future clinical innovation and research in this area.
4) be aware of surgeries for transition and their risks and
benefits.
SUMMARY:
Considerations in the care of transgender patients during the
process of transition will be presented by a psychiatrist, a
primary care physician, and a surgeon. Mental health assessment and care of transgender patients during the process of
gender transition will be discussed, including use of the
Standards of Care 7 of the World Professional Association of
Transgender Health (WPATH SOC 7), and diagnostic
changes in DSM 5 and the upcoming ICD 11. Also discussed
with be issues in assessment and care of patients with cooccurring psychiatric illness. A primary care practitioner will
discuss hormone therapy and other medical issues in the
transitioning patient. A surgeon will discuss the basics of
transgender surgeries, including what psychiatrists and
patients need to know about their risks and benefits.
IMPROVING DEPRESSION OUTCOMES IN
UNDERSERVED COMMUNITY POPULATIONS
Chair: Kenneth Wells, M.D., M.P.H.
EDUCATIONAL OBJECTIVE & SUMMARY
Forthcoming.
APPLYING FOR RESIDENCIES: ERAS, PERSONAL
STATEMENTS AND PRACTICAL REALITIES ....
THINGS YOUR VICE DEAN NEVER TOLD YOU
Chair: Stephen M. Goldfinger, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) have a clearer idea of how the process of applying
for residencies really works; 2) be able to better describe
ERAS, how do prepare a personal statement, and what sorts
of letters of recommendation to obtain; and 3) demonstrate
the ability to discuss how best to schedule and participate in
interviews.
SUMMARY:
The co-leaders of this workshop, who between them have
decades of experience advising medical students and reviewing applications for residencies, are offering this forum as a
"consumer-driven" place to bring your questions about the
entire residency application process. After talking with
many, many medical students, we've come to recognize that
a significant number of applicants are unclear about how
ERAS and the match work, and have questions about how to
choose programs to which to apply, to "sell" themselves, and
to best prepare their personal statement and maximize their
opportunities to match with their top-choice programs. We
hope that, in this highly interactive workshop, we can allay
some anxieties and help answer some, if not all, of your
questions. The sorts of topics we hope you will bring for
discussion and would be happy to address include:

Do programs have a USMLE cut off? What can I do with
my scores are lower than I hoped?

How many program should I apply to?

How far back should I go when listing community
activities or research? Should I worry more about a
skimpy cv or one that looks "padded"?

How personal should my personal statement be? Are
there things I should never talk about? Things I should
be sure to include?

From whom is it best to get my letters of
recommendation? I've worked briefly with somebody
really famous… Should I ask her for one?

Is there a best time to put in the application? If I wait
until late fall, am I waiting too long?
THE ROLE OF PEERS IN THE TREATMENT OF
PTSD: INNOVATION TO ENHANCE ACCESS TO
CARE FOR UNDERSERVED POPULATIONS
Chair: Shaili Jain, M.D.
Presenters: Steven E. Lindley, M.D., Ph.D., Craig Rosen, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize and list the different ways that peers are
being integrated into the treatment of individuals living with
PTSD; 2) understand evidence based approaches and best
practices of how to integrate peers into PTSD treatment; and
3) understand about innovative approaches that are being
implemented and investigated to utilize peers as members of
the treatment team to enhance access to care for underserved populations.
SUMMARY:
Current evidence suggests that integrating peers into the
treatment of adults with PTSD can enhance access to
treatment, particularly in underserved communities. In this
session, we review such peer interventions in three categories: peer outreach for those exposed to traumatic events;
paraprofessional peer delivery of a trauma-focused intervention after disasters and peer support for recovery from
PTSD. We describe each of these three categories, highlighting how they make PTSD treatment more accessible,
and present a conceptual model that postulates regarding
the mechanisms of action of such interventions. We also
describe a clinical demonstration project called The Peer
Support Program, an innovative service, that aims to
improve mental health care for veterans living in rural and
underserved regions of Northern California. The program
has been in the planning stages since November 2012 and
operational since February 2012. It is collaboration between
Stanford University Department of Psychiatry and Behavioral Sciences and the VA Palo Alto Healthcare System. The
program is currently offered at three VA Community Based
Outpatient Clinics (CBOCs): Sonora, Modesto and Stockton.
The primary target audience is veterans, returning from the
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2014 INSTITUTE ON PSYCHIATRIC SERVICES

will be invited to participate in a facilitated case discussion
and asked to identify a differential diagnosis, identify what
additional data they would seek to help narrow their
differential diagnoses, and select which treatment
approaches they would utilize to manage acute intoxication
and potential long-term side effects. A facilitated discussion
involving the presenters and workshop attendees will
critique the assessment and management of the case along
with highlighting critical implications for clinical practice,
research, and public health. The session will conclude by
asking the workshop attendees to reflect upon the knowledge they learned, skills they acquired, and attitudes that
were changed.
Is there a way to know how many interviews I should go
on? Are there advantages to scheduling interviews at a
particular time, or in a particular order?

Who can I trust to give me honest information about
programs? Are the residents who take me to dinner
evaluating me as well?
We cannot promise that we will be able, in the space of one
workshop, to answer all of your questions. We can, however,
promise to be honest in our responses and to share our own
experiences and perspectives.
NOV 01, 2014
EMERGING DRUGS OF ABUSE: HISTORY,
CLINICAL ASSESSMENT, AND PSYCHIATRIC
MANAGEMENT
INTERPROFESSIONAL COLLABORATIONS
BETWEEN MENTAL HEALTH AND SPIRITUAL
CARE PROFESSIONALS: OPPORTUNITIES AND
CHALLENGES
Chairs: Brian Hurley, M.B.A., M.D., Petros Levounis, M.A.,
M.D.
Presenters: Brian Hurley, M.B.A., M.D., Petros Levounis, M.A.,
M.D., Erin Zerbo, M.D., Abigail Herron, D.O., John Douglas,
M.B.A., M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify the signs and symptoms associated with
intoxication by cathinone derivatives, synthetic cannabinoids, piperazine derivatives, methoxetamine, salvia divinorum, mitragynine, and other novel synthetic psychedelic
substances; 2) organize and focus a differential diagnosis
when intoxication is suspected from substance intoxication
despite negative toxicology results on routine urine and
serum screening; 3) develop and execute a treatment plan for
managing intoxication by cathinone derivatives , synthetic
cannabinoids, piperazine derivatives, methoxetamine, salvia
divinorum, mitragynine, and other emerging drugs of abuse;
and 4) discuss the role of internet communications in the
emergence and distribution of drugs of abuse.
SUMMARY:
Emerging drugs of abuse are new psychoactive substances
that are often synthetically derived from known stimulants,
hallucinogens, or opiates but are usually unregulated due to
their novel chemical structures. Some of the more well
known of these new substances are cathinone derivatives
("bath salts"), synthetic cannabinoids ("K2 /spice"), piperazine derivatives ("Legal Ecstasy"), methoxetamine ("Legal
Ketamine"), salvia divinorum, and mitragynine ("Kratom").
Over the past few years there has been a rapid proliferation
of these novel synthetic psychedelic substances. This panel
will review the recent surge in use of these new drugs
including a discussion of their prevalence, pharmacokinetics
and pharmacodynamics. This session will introduce these
drugs' street names, subjective effects, and physical signs.
The role of internet communications in their production,
sale, and promotion will also be emphasized. Presenters will
discuss developing a differential diagnosis when intoxication
by these agents is clinically suspected in practice. General
approaches to managing the effects of acute intoxication by
one or more of these substances will be presented, including
both monitoring and treatment strategies. Given the rapid
growth in the use of these substances and their increasing
appearance in clinical presentations, a review of our current
state of knowledge has important implications for educators,
clinicians, and policy makers. This workshop will use a case
example to illustrate clinical assessment and treatment
options for these novel drugs of abuse. Audience members
Chair: Wai Lun Alan Fung, M.D., S.M., Sc.D. Presenters: John
Peteet, M.D., Joan Silcox-Smith, B.A., M.A., Purple Yip, B.A.,
M.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) Identify different ways of interprofessional collaborations between mental health and spiritual care
professionals in the provision of mental health care; 2)
Recognize some examples of interprofessional education
between mental health and spiritual care professionals; and
3) Describe examples of research endeavours investigating
the attitudes, behaviors, facilitators and barriers on interprofessional collaborations between mental health &
spiritual care professionals.
SUMMARY:
An extensive evidence base now exists in support of the
relevance of spirituality and religion in i) understanding the
etiology of many mental disorders; ii) overall clinical
assessment of a patient's mental health condition; iii) treatment planning. In particular, a position statement published
by the Royal College of Psychiatrists, UK in 2011 has
recommended that psychiatrists be willing to work with
spiritual care professionals in support of the well-being of
their patients, and indeed to encourage all mental health
colleagues to do likewise. Despite its importance, there is a
dearth of literature on how to attain this collaboration in the
real world. This proposed workshop endeavors to address
such interprofessional collaborations (IPC) between mental
health and spiritual care professionals. Four brief presentations will cover the theoretical background as well as three
dimensions of this IPC—clinical, educational and research.
The workshop presenters—consisting of two academic
psychiatrists (from Harvard and the University of Toronto), a
hospital chaplain and director of religious/spiritual services,
and a mental health worker with a Master's degree in
Divinity—are all experienced in this IPC. Some examples to
be presented include several educational initiatives aimed at
enhancing such IPC, innovative mind-body-spirit practices
utilized by a chaplain in psychiatric day treatment program,
different consultation models addressing such IPC, and a
national study designed to investigate the spiritual care
beliefs and practices of clergy members regarding mental
illness. After the presentations, participants will discuss what
approaches have proven most effective and why, as well as
opportunities and challenges in promoting such IPC.
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AMERICAN PSYCHIATRIC ASSOCIATION
conditions that result from psychiatric treatment and
provide counseling in preventive health care. The general
medicine training received by psychiatry residents is
minimal and often limited to the required minimum of 4
months in the internship year. Several models for enhanced
medical training in psychiatric residency have been
proposed and some are being implemented in residency
programs across the country. However, there is little
consensus across training programs on the nature, extent
and timing of this training. In this workshop, we will briefly
review existing training models that incorporate general
medicine training beyond the required minimum. We will
then propose a model curriculum that is designed to
improve the general medicine skills of psychiatrists and
prepare them to be leaders in integrated care. We will outline
the core principles and goals for this curriculum and provide
a framework to implement this training as a continuum
across residency. We will review the definition of resident
competence in psychiatry training and discuss its applicability to a role in integrated care. Also, we will discuss
strategies to continue this education throughout the lifetime
of a practicing psychiatrist. The second half of the session
will be allotted for active audience involvement. We will
encourage the audience to share their experience in
developing innovative educational programs at different
institutions and in diverse settings. We hope that this
discussion will generate the benefits, challenges, and
potential solutions in changing psychiatry residency
curricula. We will also invite the audience to engage in a
discussion on implications for the future of psychiatric
practice. The presenters will include a community psychiatrist, community mental health center director, clinical
educator and internist/psychiatrist, and a residency program
director.
CUSTOMER SERVICE AS MEANINGFUL
RECOVERY ORIENTATION AND A TEMPLATE FOR
SYSTEM TRANSFORMATION
Chairs: Michael J. Sernyak, M.D., Sacha Agrawal, M.D., M.Sc.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the potential impact of focusing on
customer service and satisfaction on the goal of delivering
high quality recovery-oriented behavioral health services; 2)
identify the elements of what comprises excellent customer
service through the use of examples in other service organizations; and 3) identify improvements that can be made in
their own workplaces to improve the experience of service
users.
SUMMARY:
A notable recent development in the rapid evolution of
healthcare in North America is a focus on customer service.
Borrowing from lessons learned in other service-oriented
sectors, hospital administrators have begun to target high
patient satisfaction as a way of increasing customer loyalty
and improving sales and profits. We argue that patient
satisfaction is also a critical and under-emphasized dimension of quality in public sector behavioral health, where
asylum-era attitudes toward service users frequently persist.
In this interactive workshop, we will describe the concepts of
customer service, customer experience and customer
satisfaction by drawing on examples from participants'
everyday lives as customers. Next we will review the
academic literature on patient satisfaction in healthcare,
highlighting its potential value and also the conceptual and
methodological problems that remain. We will then consider
how a customer service focus can facilitate the transformation of behavioral health to a recovery orientation. Our
experiences at the Connecticut Mental Health Center (New
Haven, CT) and the Centre for Addiction and Mental Health
(Toronto, Canada) will serve as a springboard for discussing
5 tips for improving quality of care by improving customer
service. Finally, participants will work in small groups to
develop customer service innovations for their own
workplaces.
SEXUAL TRAFFICKING OF THE BLACK FEMALE:
SURVIVING MODERN DAY SLAVERY
Chairs: Kimberly A. Gordon, M.D., Andrea M. Brownridge,
J.D., M.D., M.H.A.
Presenters: Denese Shervington, M.D., M.P.H., Napoleon B.
Higgins Jr., M.D., Andrea M. Brownridge, J.D., M.D., M.H.A.,
Kimberly A. Gordon, M.D., Richelle Long, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify risk factors that increase vulnerabilities for
African American children and youth to become victims of
sex trafficking; 2) understand the concept of normalized
sexual harm and its impact on the desensitization of AfricanAmerican youth; 3) provide mental health clinicians with the
tools to accurately identify, diagnose and treat the mental
and physical health needs of women exploited by sexual
trafficking; and 4) propose preventive based strategies that
mental health clinicians may employ to aid in the antitrafficking movement.
SUMMARY:
Modern human slavery, also known as human trafficking, is
a global health concern. As declared by President Barack
Obama, "[human trafficking] ought to concern every
community, because it is a debasement of our common
humanity. It ought to concern every community, because it
tears at our social fabric. It ought to concern every nation,
because it endangers public health and fuels violence and
organized crime." In 2003 the Trafficking Victims Protection
Act's (TVPA) focus was broadened to include domestic
DEVELOPING A MODEL CURRICULUM TO TRAIN
PSYCHIATRISTS AS LEADERS IN INTEGRATED
CARE
Chair: Aniyizhai Annamalai, M.D.
Presenters: Michael J. Sernyak, M.D., Robert M. Rohrbaugh,
M.D., Lori E. Raney, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the changing role of psychiatrists in
patient centered integrated health care; 2) describe existing
models of enhanced general medicine training in psychiatry;
3) discuss the core principles and goals of a model curriculum to train psychiatrists to be leaders in health care; and
4) discuss the impact of changing health care needs on scope
of psychiatric practice .
SUMMARY:
The increasing emphasis on integrated health necessitates a
new look into the role of psychiatrists and provides an
opportunity for them to be leaders in health care. For
patients in the public health sector, the mental health center
is often the only point of contact with the health care system
and at a minimum, psychiatrists have to be aware of
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
human trafficking bringing attention to the epidemic of
injustice that destroys so many lives. According to the U.S.
Department of State, human trafficking is an umbrella term
for activities involved when someone obtains or holds a
person in compelled service. Sex Trafficking and Child Sex
Trafficking are two of the most devastating forms of
enslavement that are captured by this brand of modern day
slavery. Per the Trafficking Victims Protection Act (TVPA),
sex trafficking occurs when a commercial sex act is induced
by force, fraud, or coercion, or in which the person induced
to perform such an act has not attained 18 years of age. Sex
trafficking has devastating consequences for minors,
including long- lasting physical and psychological trauma,
disease including HIV/AIDS, drug addiction, unintended
pregnancy, malnutrition, social ostracism, and death. Sadly,
of the confirmed sex trafficking victims in the United States
whose race was known, 26 percent were white and 40
percent were black. This disparity is borne out by the risk
factors for recruitment into trafficking: young age, poor
education, history of abuse or violence, single parenting,
desperate social economic circumstances and war
circumstances. Notably, the foster care system unwittingly
supplies a ready source of vulnerable at-risk youth.
According to the National Center for Missing and Exploited
Children, 60 percent of runaways who are victims of sex
trafficking had been in the custody of social services or foster
care. Essentially, the circumstances that lead minors into
foster care are often what make them especially vulnerable
to sex trafficking. Without an involved parent, the "pimprecruiter" initially enters their life in the role of protector.
Studies demonstrate that victims of sexual trafficking have
greater mental health needs and more severe trauma
compared to victims of other crimes, and can be
encountered in emergency departments, health clinics,
family planning clinics and HIV/AIDS clinics. Human
Trafficking indicators, or "red flags" include living with an
employer, inability to speak to individual alone, scripted and
rehearsed responses, submissive or fearful affect, and under
18 and in prostitution. Because mental health providers
often provide the most intensive interview during a medical
encounter, there is tremendous opportunity to identify,
assist, and advocate for this vulnerable population.
quite fulfilling or quite painful, and the current political and
religious battles regarding homosexuality often exacerbate
their distress. These individuals often experience the
religions of their youth as anti-gay and hostile to their
emerging sense of gay affirmative identities. For many, an
important task of coming out and consolidating their identity is coming to terms with their spirituality and finding a
new context for their faith. In this workshop, we will examine
these issues through psychotherapeutic case presentations
and clinical vignettes. Howard Rubin, M.D., will discuss his
psychotherapy with a Catholic man struggling to reconcile
his faith with his sexuality. Ellen Haller, M.D., will present
the case of a lesbian who left the fundamentalist Protestant
faith of her youth after she came out. Our discussant will be
Dr. Donal Godfrey, a Catholic priest who is the Executive
Director of University Ministry at the University of San
Francisco.
50 SHADES OF GRAY: ETHICAL CHOICES IN
ADDICTION MEDICINE
Chair: Timothy K. Brennan, M.D., M.P.H.
Presenters: Abigail Herron, D.O., Petros Levounis, M.D., M.A.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the roles of addiction medicine professsionals regarding supply reduction; 2) handle patients with
prescriptions that seems dubious or fraudulent; and 3) feel
comfortable navigating a patient dynamic when the patient
is lying.
SUMMARY:
The workshop will be focused around a challenging clinical
vignette that presents a variety of potential choices, each
with specific ethical consequences for the patient and
physician. After discussing the vignette, there will be a structured debate between two addiction medicine clinicians: Dr.
Petros Levounis and Dr. Abigail Herron. They will use a
common discussion technique in ethical discourse called
anchoring, whereby each participant begins their discussion
from a rigid viewpoint, and through discourse a consensus is
gradually reached. The vignette will be an adult male with a
history of severe opioid use disorder who presents to an ER
in Manhattan requesting admission for opioid detoxification
and rehabilitation. The patient is very well known to the
physician, having completed a 4 week inpatient stay for
opioid use disorder several weeks prior to seeking readmission. In the interval weeks since discharge the patient has
relapsed on opioids by finding several physicians in Brooklyn
to write him prescriptions for his drug of choice. Upon
readmission to the inpatient unit his belongings are
searched and recorded, and one of his prescriptions for
opioids is mistakenly placed in his chart, rather than in his
locker with the rest of his supplies. The physician happens to
find this prescription and suspects it was written at a "pill
mill", or perhaps written by a physician who didn't know
that the patient had an addiction to opioids. Should the
prescription, which represents the very crux of this patient's
problem, be returned to the patient since it is their legal
property? Or should the physician throw it away?
WRESTLING WITH THE ANGEL: PSYCHOTHERAPY,
STRUGGLE AND FAITH IN LESBIANS AND GAY
MEN
Chair: Howard C. Rubin, M.D.
Presenters: Donal Godfrey, D.Min., Ellen Haller, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) appreciate the complex interplay of religion,
spirituality, and sexual orientation in the lives of gay men
and lesbians; 2) understand how religion and spirituality
may play prominent roles in the coming out process; and 3)
apply some of the insights gained in the workshop to their
own psychotherapeutic work with lesbians and gay men.
SUMMARY:
Abstract: For lesbians and gay men who are struggling with
their sexual orientation, their relationship to religion may be
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AMERICAN PSYCHIATRIC ASSOCIATION
SUMMARY:
The objective of this workshop is to encourage recovery
oriented psychiatrists to implement informal as well as
formal ways to introduce recovery oriented education into
programs which remain dominated by mainstream, biologically oriented values. The workshop will consist of three
parts. First, we will overview the institutional structures that
serve as potential obstacles to a recovery oriented transformation of training and education. Second, we will describe
methods and strategies that can be used to remedy them.
Third, we will present a role play exercise we have been using
to introduce recovery principles to medical students during
their psychiatry clerkships. The analysis of the current
system will examine the values, policies, finances, curriculum content and clinical training that support the currently
dominant, predominantly biomedical paradigm. In the
second section, we will discuss several approaches that can
be used in addition to the established curriculum to
introduce recovery oriented values and approaches. These
include discussion of: involvement of residents in postresidency educational opportunities; resident and student
involvement in consumer-provider dialogues; faculty
support for resident and medical student interest groups;
opportunities for people with lived experience to serve as
teachers; recovery oriented role plays and curriculum
content for students' psychiatry clerkships. A recovery
oriented role play exercise will be demonstrated and
discussed, including medical student comments on its use in
3rd year psychiatry clerkships.
PSYCHIATRIC ADVANCE DIRECTIVES: WHERE TO
START? - IMPLEMENTATION STRATEGIES FROM
ACADEMIC MEDICAL CENTERS, A STATE
HOSPITAL, AND AN ACT TEAM
Chair: Rachel Zinns, M.D., Ed.M.
Presenters: Abha Gupta
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify strategies for successful implementation
of Psychiatric Advance Directives (PAD) that target administration, providers, and consumers; 2)Participants should be
able to anticipate challenges associated with initiation of a
Psychiatric Advance Directives implementation plan; and
3)Participants will have had the opportunity to discuss
efforts towards PAD implementation in their various
treatment settings and to share experiences with different
implementation strategies.
SUMMARY:
Consumer autonomy, improved treatment adherence,
enhanced treatment alliance, and reduced violence are
among the many supposed benefits of psychiatric advance
directives (PAD). Despite reports of these and other benefits
of PAD, strong consumer interest in PAD, and national policy
oversight moving towards a standardization of PAD, their
use has not been widespread. Indeed, there have been
numerous reports in recent years of consumer and clinician
attitudes regarding PAD, content of PAD documents, and
factors related to their completion process. Yet little has been
written about the implementation of PAD at the organizational level, especially with regard to dissemination and
access to documents and the honoring of PAD. We will
present several examples of PAD implementation that
address administrative and legal issues, documentation and
dissemination through EMR, provider training and increaseing provider readiness, consumer education, and peeradvocate training. We will describe efforts to tailor
implementation strategies to both perceived and real-time
barriers. Strategies which were most helpful, as well as
obstacles and resistance frequently encountered, will be
highlighted. We will report on the process of evaluating
various implementation and intervention strategies,
focusing on the relationship of implementation strategies to
clinician, patient, and service system outcomes. Participants
will be encouraged to discuss their experiences with PAD
implementation. Especially because there is little guidance
in the literature about preparing consumers and providers
for PAD implementation, we hope to provide a forum for
sharing tips from successful implementation efforts,
problem-solving for challenges faced by participants,
networking, and information-exchange.
THE VALUE OF HIRING PEOPLE WITH LIVED
EXPERIENCE (PEERS) IN THE MENTAL HEALTH
WORKFORCE
Chair: Terri Byrne
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand mental health challenges; 2) discuss
the challenges; and 3) understand how one city in California
handled the challenges.
SUMMARY:
People with lived experience of mental health challenges are
an important addition to the mental health workforce, and
they are making unique and valuable contributions in
greater numbers than ever before. Unfortunately, the full
range of their talents and potential goes untapped because
the organizations that employ them are unsure how to
successfully support and empower peer employees. We
believe the best people to help the mental health workforce
overcome barriers to peer employment are other peer
employees themselves. By listening and responding to the
voices and perspectives of employees with lived experience,
employers can develop supports and opportunities that will
meet the long-term needs of peer employees and create a
thriving peer workforce that can help to transform the
mental health system. For the first 30 minute of this
interactive forum, panelists with lived experience will discuss
the challenges they face in the mental health workforce, as
well as the kinds of supports and opportunities that have
been most helpful to them. Audience members will have the
chance to ask questions and take full advantage of the
panelists' real-world expertise. For the final portion of the
formal presentation, , the medical chief of the south county
behavioral health recovery services clinic in Redwood City
California, will discuss his experience, hiring and working
INFORMAL STRATEGIES TO AID RECOVERY
ORIENTED TRANSFORMATION OF BIOMEDICAL
EDUCATION AND TRAINING
Chairs: Robert S. Marin, M.D., Wesley E. Sowers, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe institutional structures that prevent
recovery oriented transformation of psychiatry education
and training; 2) describe informal methods and strategies for
circumventing obstacles to recovery oriented psychiatric
education and training; and 3) demonstrate a role play that
contrasts biomedical and recovery oriented clinical skills .
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
with peers. The remaining time will be used to hear from the
audience about their experience with hiring and working
with people with lived experience and how to go about
overcoming barriers to employment for these valuable
members of the team.
substance use disorders but is particularly targeted towards
members in training and early career psychiatrists.
MEDICAL MARIJUANA IN ARIZONA: EXPERIENCES
IN THE PUBLIC MENTAL HEALTH SYSTEM
Chair: Gretchen B. Alexander, M.D.
Presenters: Aaron V. Riley, M.D., Nancy Van Der Veer, Psy.D.,
Devna Rastogi, M.D., Shabnam Sood, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify evidence-based indications for medical
marijuana; 2) explore strategies for discussing medical marijuana with patients with schizophrenia-spectrum disorders;
3) review the evidence regarding the relationship between
cannabis use and psychosis; 4) discuss clinical and policy
implications of physician involvement in medical marijuana
certification; and 5) identify available varieties and potencies
of medical marijuana as well as implications for clinical
effects.
SUMMARY:
Workshop Purpose: The aim of this workshop is to provide a
forum in which participants can update their knowledge of
current evidence regarding therapeutic benefits and harms
of medical marijuana, as well as discuss both clinical and
policy implications of current medical marijuana statutes.
Marijuana has historically enjoyed a reputation as a
psychoactive substance with a favorable harms profile. In
spite of substantial evidence that a connection exists
between marijuana use and the onset of psychosis, the belief
that marijuana is an entirely benign substance remains quite
common. In 2010, the Arizona State Legislature passed
legislation allowing the use of marijuana for the medical
treatment of specified conditions. The medical marijuana
program subsequently created by the Arizona Department of
Health Services was intended to ensure access to medicinal
marijuana for qualified conditions while minimizing the risk
that the program would promote the recreational use of
marijuana. Although the Arizona program is still fairly new,
our treatment of a series of patients with psychosis and
medical marijuana cards over the last year has suggested
that availability of medical marijuana may pose certain
challenges in the treatment of the severely mentally ill. In
this workshop we will review the evidence for both
therapeutic and adverse effects of marijuana using
interactive clinical vignettes, and will discuss specific aspects
of the Arizona program which may be interesting to
clinicians practicing in states preparing to adopt medical
marijuana laws. There will be a breakout into small facilitated discussion groups to share information about clinical
cases and as well as experiences with medical marijuana
programs in participants' own states.
NOV 02, 2014
60/60: ALL OF ADDICTION TREATMENT IN 60
MINUTES AND 60 SLIDES
Chairs: Petros Levounis, M.A., M.D., Abigail Herron, D.O.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) Discuss two major psychosocial interventions for
the treatment of substance use and other addictive disorders; 2) List three medications approved by the Food and
Drug Administration (FDA) for the treatment of opioid use
disorders; and 3) Compare nicotine replacement therapies
with other medications in the treatment of tobacco use
disorders.
SUMMARY:
In recent years, Psychiatry has witnessed the development of
many exciting clinical innovations in the treatment of
patients who suffer from substance use and other addictive
disorders. While the science of the treatment of substance
use disorders is advancing at a significant rate, the
implementation of even the most "tried and true" of these
treatment innovations has been slow. Several lines of
evidence suggest that the majority of mental health systems,
addiction centers, and psychiatrists in private practice resist
adoption of these new practices. In this workshop, we will
review the most recent evidence of safe and effective
psychosocial and pharmacological interventions for patients
who suffer from addiction. We will review best practices for
the use of Food and Drug Administration (FDA) approved
medications as well as experimental pharmacological agents
with significant promise in the treatment of such disorders.
In addition, we will discuss the integration of motivational
interviewing for effectively engaging the ambivalent (or even
completely disinterested) psychiatric patient in addiction
treatment, a common problem in everyday clinical practice.
Participants will be invited to bring their own experience
treating patients with substance use disorders and to work
with the faculty on formulating creative options for
implementing these new approaches in clinical practice. A
second goal of this workshop is to provide a concise and
innovative instruction tool in the teaching of Addiction
Psychiatry. Psychiatrists these days do much more than treat
patients. Educating people about addiction and helping
them understand the disease from a medical perspective is a
ubiquitous request. From giving a Grand Rounds presentation to seasoned attending physicians to training hospital
staff through in-service programs to responding to the
media, we are often called on to talk about mental illness and
its treatments. In this workshop, we will strictly use 60
minutes and 60 slides with no more than 60 words per slide
to deliver a lecture that can be used in a variety of
educational settings. During the discussion part of the
workshop, the presenters will invite participants to critique
the presentation; change, add, or delete topics and slides;
and discuss the usefulness of such an admittedly ambitious
undertaking. The workshop is open to all psychiatrists who
would like to learn more about the effective management of
LONELINESS: THE MISSING PIECE IN THE
PSYCHIATRIC TREATMENT PLAN OF LONELY,
SUICIDAL, ELDERLY INDIVIDUALS
Chairs: Ali A. Asghar-Ali, M.D., Sheila M. Lobo Prabhu, M.D.
Presenter: Jennifer O'Neil, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) describe the dimensions of loneliness; 2) describe
a history taking approach for the cognitive, emotional,
personality, environmental, and life event antecedents to
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AMERICAN PSYCHIATRIC ASSOCIATION
loneliness, the moderating and mediating factors, and the
protective factors; 3) identify how personality and life events
can predict loneliness in the elderly based on the findings of
the Georgia Centenarian study; 4) appreciate how loneliness
and life events can predict suicidal behavior in a diathesisstress model; and 5) apply knowledge about loneliness and
life events to a treatment planning approach for suicidal,
elderly individuals.
SUMMARY:
Recent studies have supported a diathesis-stress model for
the effects of loneliness and negative life events as predictors
for hopelessness and suicidal behaviors. Innamorati et al
performed psychological autopsies of completed suicides in
an old-old population. Their findings suggest that clinicians
invested in minimizing suicidal behaviors in older adults
should be particularly attentive to loneliness and the
absence of social support. These two conditions contribute
to the individual's feeling of hopelessness, especially in the
setting of stressful life events. In this workshop, we suggest
identifying loneliness as an independent problem on the
treatment plan for elderly patients who report loneliness.
Participants will be provided with the description of different
types of loneliness. We will then describe the process of
obtaining a detailed psychosocial assessment with the
emphasis on assessment of the cognitive, emotional, personality, environmental, and life-events antecedents to
loneliness, the moderating and mediating factors, and the
protective factors. Finally, a framework for identifying goals,
objectives and interventions in treatment planning to
decrease loneliness will be presented. Two clinical cases will
illustrate the application of a model to treat lonely, suicidal,
elderly individuals using validation, mentalization, reality
orientation, and socialization to help in the formation of a
stable "self." This approach targets loneliness as an
independent entity by addressing the need for enhanced
relationships, social well- being, and communication skills in
lonely individuals with the ultimate goal of reducing the risk
of suicide.
These treatments will include immediate necessary treatment, as well as on-going treatment. In this discussion, we
will also note when to treat and when to refer to our
colleagues in the medical emergency department or internal
medicine. The talk will be given by an emergency medical
physician and an emergency psychiatrist.
DEADLY EMERGENCIES IN PSYCHIATRY: KEYS TO
RECOGNIZE AND TREAT NMS, SEROTONIN
SYNDROME, EXCITED DELIRIUM AND OTHER
DISEASES THAT KILL
TRANSLATING RESEARCH INTO PRACTICE:
MANAGING BEHAVIORAL AND PSYCHOLOGICAL
SYMPTOMS OF DEMENTIA IN THE ERA OF BLACK
BOX WARNINGS
BIPOLAR DISORDER TREATED IN PRIMARY CARE
SETTINGS: STEPS TOWARD A STANDARD OF
CARE
Chair: John S. Kern, M.D.
Presenters: Joseph M. Cerimele, M.D., Patrick S. Runnels, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) state 3 models used for care of bipolar disorder in
primary care settings; 2) use screening instruments for
bipolar disorder appropriately; and 3) participate in the
ongoing development of a standard of care for bipolar
disorder in primary care.
SUMMARY:
Collaborative care models have been proven effective for the
care of depressive illness in primary care settings. Expanding
evidence-based care to the large number of individuals with
bipolar disorder seen in these settings is necessary, but no
systematic work on assessment and treatment has been
done yet. Some early adopters have begun to construct
models of care and to gather data on this treatment, and will
share their findings, with an eye toward building a research
agenda and a standard of care for these patients, and
developing a community of providers interested in this work.
Dr John Kern will present data on a multi-year project of
bipolar care in an FQHC setting, Dr Joseph Cerimele will
review his publications on the demographics of and quality
issues with bipolar care in the State of Washington MHIP
program, and Dr. Patrick Runnels will discuss issues of
diagnosis in patients presenting with mood symptoms in
primary care settings.
Chair: Kimberly Nordstrom, J.D., M.D.
Presenter: Michael Wilson, M.D., Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to understand: 1) numerous medical illnesses and
conditions that may go unrecognized in a medical emergency department, with the patient being transferred to
psychiatry emergency department or inpatient; 2) how to
recognize serious medical conditions that have psychiatric
symptoms; and 3) when to treat and when to refer the care to
medical teams; 4) basic treatment of each medical condition.
SUMMARY:
This workshop will explore the numerous medical emergencies that, because of prominent psychiatric symptoms,
sometimes end up being recognized on psychiatric services.
Some of these conditions are related to use of psychiatric
medications but most are medical illnesses that have no
relationship to psychiatry. Each emergent condition or
illness will be reviewed, to include common signs and
symptoms, to aid the practitioner in recognition of the
emergency. After this review, treatments will be discussed.
Chair: Rajesh R. Tampi, M.D., M.S.
Presenter: Deena J. Tampi, M.B.A., M.S.N.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) define behavioral and psychological symptoms of
dementia (BPSD); 2) enumerate the epidemiology and
neurobiology of BPSD; 3) describe an evidence-based assessment protocol for BPSD ; 4) elaborate on the evidence based
management of BPSD; and 5) highlight the medicolegal
issues in the management of BPSD.
SUMMARY:
Behavioral and Psychological Symptoms of Dementia
(BPSD) refers to a group of non-cognitive symptoms and
behaviors that occur commonly in patients with dementia.
They result from a complex interplay between various
biological, psychological and social factors involved in the
disease process. BPSD is associated with increased caregiver
burden, institutionalization, a more rapid decline in cognition and function and overall poorer quality of life. It also
adds to the direct and indirect costs of caring for patients
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
with dementia. Available data indicate efficacy for some
non-pharmacological and pharmacological treatment
modalities for BPSD. However, recently the use of
psychotropic medications for the management of BPSD has
generated controversy due to the increased recognition of
their serious adverse effects. In this presentation we will
discuss the epidemiology, neurobiology, diagnosis and
management of BPSD. We will also provide an evidence
based guideline to assess and treat these patients. Finally, we
will elaborate on the recent controversies in the treatment of
BPSD.
THE OREGON STATE HOSPITAL/OREGON HEALTH
AND SCIENCES UNIVERSITY COLLABORATION: A
UNIQUE EMPLOYMENT OPPORTUNITY FOR
EARLY- CAREER FORENSIC PSYCHIATRISTS
Chair: Joseph Chien, D.O.
Presenters: Karl Mobbs, M.D., Christopher J. Lockey, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) identify challenges faced by early-career forensic
psychiatrists in establishing a professional identity; 2)
understand factors pertaining to psychiatrist burn-out and
job satisfaction; and 3) recognize the utility of interinstitutional collaboration to diversify psychiatric work and
create a sense of personal accomplishment.
SUMMARY:
Objective: To present an innovative program involving a
collaboration among a State forensic hospital, a forensic
evaluation service, and a university department of psychiatry, designed to attract and retain early-career forensic
psychiatrists. Method: The workshop will have three
speakers. The first will provide an introduction to the Oregon
State Hospital (OSH) and its storied history, provide a brief
overview of the legal mechanisms by which the hospital
admits its forensic population, and review relevant patient
demographic statistics. The second speaker will discuss the
planning and design of the program for forensic psychiatrists, including the mutually beneficial collaboration
between Oregon Health and Sciences University (OHSU) and
the OSH, academic opportunities for psychiatrists including
providing lectures for and supervising OHSU forensic
psychiatry fellows, residents and medical students, and the
implementation of a unique "forensic rotation" that
forensically-trained psychiatrists may elect to participate in
for three months of each year. The third speaker will present
"a day in the life" of a psychiatrist on the Forensic Evaluation
Service (FES) rotation, discussing the types of evaluations
that are done on the service, and describing educational
aspects of the rotation, such as weekly multidisciplinary
conferences. Discussion: Early career forensic psychiatrists
face the difficult task of establishing a professional identity
that balances forensic, clinical, and, if desired, academic
work. The OSH-OHSU collaboration was designed to attract
psychiatrists who recently completed forensic fellowship
training, by offering a built-in opportunity to spend a portion
of each year working in the FES doing court-ordered
competence to stand trial and insanity evaluations. An
additional rationale behind the "rotation" system was to
prevent burnout common in psychiatrists by adding task
variety and attempting to increase the sense of personal
accomplishment in participants. At the same time, the State
Hospital gained a group of skilled and motivated clinicians,
allowing for decreased reliance on temporary employees.
Conclusion: We present a collaboration among an academic
center, a state hospital, and a forensic evaluation service that
has produced a unique academic forensic psychiatrist
position that appears to be beneficial to all parties. The
position appears particularly attractive to recent forensic
fellowship graduates seeking to find a job that balances
clinical and forensic work.
References:
CANNABIS AND PSYCHOSIS: STUDYING THE
ASSOCIATION FROM PRENATAL EXPOSURE TO
SCHIZOPHRENIA
Chair: Jaskanwar S. Batra, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand that cannabis is neither universally
safe nor dangerous as it relates to predisposition to
psychosis; 2) learn about periods of time when the brain is
especially vulnerable to the effects of cannabis; 3) learn
about gene X environment (cannabis in this case) interactions and the development of psychosis; and 4) learn
about when cannabis appears to benefit cognition.
SUMMARY:
The public debate on the safety of cannabis as it relates to
the development of psychotic disorders seems to be polarized into two camps: Safe or Unsafe. There is now a more
nuanced view of the safety of alcohol and nicotine. Public
education about them, and times when they are particularly
dangerous, such as pregnancy and early development years
and have started to bring down use of these substances
during these particularly harmful periods. In this presentation, you will see that the data suggests that there are
developmental periods of greater vulnerability for the brain
and there are other times when cannabis does seem to be
harmful and times when it appears to benefit cognition.
Periods of vulnerability seem to correlate with developmental stages of rapid brain growth, e.g., intra-uterine,
infancy and early teen years. Moreover, we will examine the
dose dependent effect especially during these times. We will
also examine the data on genetic risk for psychosis and how
that presents in the face of cannabis exposure. In other
words, we will examine the gene-environment relationship
of cannabis and psychosis. There are times when cannabis
appears to be safer; at least as it relates to the predisposition
to psychosis. There may even be times when there appear to
be cognitive benefits from use of cannabis in moderate
amounts. This presentation will equip you with information
to inform both patient care as well as public policy to advise
on when cannabis appears to be dangerous, what makes
cannabis more dangerous for some rather than all and when
it appears to be safer.
Cooke BK. Becoming a real doctor: My transition from fellowship to faculty.
Journal of the American Academy of Psychiatry and the Law 40:132-4,
2012.
Kumar S, Sinha P, Dutu G. Being satisfied at work does affect burnout
among psychiatrists: A national follow-up study from New Zealand.
International Journal of Social Psychiatry, 59(5): 460-7, 2012.
49
AMERICAN PSYCHIATRIC ASSOCIATION
TREATING MENTAL ILLNESS? THERE IS AN APP
FOR THAT: A WORKSHOP ON SMARTPHONE APPS
IN PSYCHIATRIC PRACTICE
THE OPIOID EPIDEMIC IN AMERICAN CHILDREN:
EQUIPPING OURSELVES FOR SUCCESS
Chair: Timothy K. Brennan, M.D., M.P.H.
Presenter: Timothy K. Brennan, M.D., M.P.H.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) recognize the severity of the opioid epidemic
among American children; 2) acquire diagnostic tools to
better screen for addicted children; 3) define evidence-based
medical and non-medical treatment strategies; and 4)
practice learned objectives through case-based clinical
vignettes.
SUMMARY:
Opioid overdoses kill more young adults in the US than
overdoses of any other drug. With the proliferation of
prescription opioids (oxycontin, hydromorphone, etc.), there
has been a tremendous increase in opioid use disorders
among all Americans, specifically children and young adults.
While statistics regarding youth opioid disorders are
alarming, there has not been a concurrent increase in
formalized medical education for psychiatrists (or pediatricians). Because drug abusers are often highly stigmatized
in society, their healthcare utilization tends to be fragmented
and sporadic. Psychiatrists need to equip themselves with a
cohesive skill-set to provide optimal care to such a high-risk
patient population. This workshop will begin with a brief
lecture-based review of the opioid epidemic among American children. We will then discuss the various screening and
diagnostic tools available to clinicians and provide a
referenced bibliography for further reading. Next, we will
define evidence-based medical and non-medical treatment
strategies employed in the treatment of opioid use disorders.
The workshop will then transition to small group learning
exercises where participants will practice learned objectives
through case-based clinical vignettes. After the small group
sessions, each group will present their particular conclusions
to the group-at-large, and the workshop leader will highlight
the learning objectives. The workshop will conclude with a
question and answer session.
Chair: Ganesh Gopalakrishna, M.D.
Presenters: Sriram Chellappan, Ph.D., Drew Clark, B.Sc.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) understand basics of apps in the smartphone
industry; 2) discuss the literature on the use of app in mental
health delivery and future opportunities of the field; 3) know
some of the best apps in the market with a demonstration of
the same; 4) develop an app for your practice on your own?;
and 5) demonstrate the app developed at University of
Missouri.
SUMMARY:
The concept of mHealth, defined as the use of mobile and
wireless devices such as smartphones to promote health
objectives has received growing attention worldwide. (WHO,
2011). This utility holds great promise for treating mental
illness in increasing access to visits and providing real time
symptoms monitoring. According to the WHO mHealth is
practiced, in some form, by 83% of member nations of the
World Health Organization (WHO, 2011). Leading the growth
in mhealth is the increasing availability and use of
smartphones including by people with serious mental illness
(Ben- Zeev, Davis, Kaiser, Krzsos, & Drake, 2013). There have
been a number of smartphone based apps designed to help
patients with mental illnesses. There are apps which allow
patients to self-screen for various mental disorders, provide
referrals to nearby resources and education about mental
health diagnoses, as well as track their treatment progress.
There are also treatment apps including but not limited to
mindfulness and, relaxation training, biofeedback, and
instant chat with crisis counselors. Many psychiatrists and
mental health providers have been utilizing these apps in
their practice. The existence of so many apps implies that the
needs among providers are diverse and may not be met by
one single app. Despite the growth mHealth there is a
general lack of knowledge by providers of this medium. This
leads to mHealth not being utilized by most providers in
behavioral health. This workshop titled, "Treating mental
illness? There is an app for that,"is designed to increase
awareness among provides about this emerging science
which has the potential to revolutionize the practice of
behavioral medicine. This session will introduce the basics of
the smartphone apps and the current evidence for it. The
session will then review some of the best apps for mental
health in the market with respect to features, shortcomings
and advantages. This session will provide the attendees the
opportunity to learn about various smartphone apps and
help them choose what they may feel fit for their practice.
We will also demonstrate the app we have developed at
University of Missouri and present some preliminary
findings of research of the efficacy of the same.
References
EMERGING PROBLEMS IN ADDICTION
Chair: Frances R. Levin, M.D.
Presenters: Timothy W. Fong, M.D., Mark Klieman, Ph.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) obtain skills to effectively recognize, diagnose and
treat common behavioral addictions; 2) identify emerging
evidence-based treatment options for cannabis use disorders; and 3) understand policy and public health implications of cannabis decriminalization and legalization.
SUMMARY:
This workshop will first review the latest scientific work to
characterize and understand the non-substance-related
addictive disorders, commonly called behavioral addictions.
A wide number of these conditions and syndromes have
been described but clinicians and researchers are most likely
to encounter gambling disorder, hypersexual behaviors and
video game/internet use disorders. Emphasis will be placed
on what is known, and what is not known about the etiology
clinical course, and treatment options for these conditions
and behaviors. Second, this workshop will discuss the
pharmacology of marijuana, including cannabinoid ligands
that bind to cannabinoid receptors and their potential
therapeutic and adverse effects. Cannabis is the most widely
Ben-Zeev, D., Davis, K. E., Kaiser, S., Krzsos, I., & Drake, R. E. (2013).
Mobile technologies among people with serious mental illness: Opportunities for future services. Adm Policy Ment Health, 40(4), 340-343. doi:
10.1007/s10488-012-0424-x
WHO. (2011). mHealth New horizons for health through mobile technologies: Second global survey on eHealth, from
http://www.who.int/goe/publications/goe_mhealth_web.pdf
50
2014 INSTITUTE ON PSYCHIATRIC SERVICES
used illicit drug in the U.S., with 10% of users ending up
dependent. Results of clinical trials testing pharmacologic
treatments for cannabis-dependent individuals, a rapidly
evolving area of research, will also be presented, and
promising pharmacogenetic approaches will also be
discussed. In the laboratory setting, agonists (e.g. dronabinol
[oral thc], nabilone) have shown some promise as well as
combined pharmacotherapies (such as dronabinol and
lofexidine). There have been a limited number of outpatient
clinical trials, with dronabinol, N-acetylcysteine and
gabapentin showing some benefit. Lastly, this workshop will
review policy issues and public health implications of
cannabis legalization, decriminalization and medical
cannabis.
are offering this workshop as a "consumer-driven" place to
bring your questions about life after residency. Although
essentially or residency training programs provide thoughtful and well-designed didactics and clinical supervision, we
have found that residents around the country consistently
struggle with issues- and the lack of information- about what
to do after residency is over. The sorts of topics that we hope
you will bring for discussion include:

Is doing a fellowship essential? How about if I want a
career in academia?

Does taking a non-accredited fellowship make

sense?

When should I start looking for jobs? Is it like interviewing for residency? What should I be asking about besides
salary and hours?

Should I change towns, or stay where I trained? Why?

Everyone keeps warning me the entire healthcare
system is changing. How do I prepare for that?

How does one set up a private practice? Should I look for
salaried or self-employed positions?

Does anyone do psychoanalysis anymore?

Can I have an academic career and still earn a decent
living?

I want to be a..? How do I get there?

I'm on a J-1 visa. What are my options?
Of course, these are not meant to be a comprehensive list,
but are examples of the kinds of questions we'd be happy to
(help) answer!
BEYOND THE LAUNCHING PAD: A FORUM FOR
PLANNING FOR LIFE AFTER RESIDENCY
Chair: Stephen M. Goldfinger, M.D.
Presenters: Marshall Forstein, M.D., Ellen Haller, M.D.
EDUCATIONAL OBJECTIVE:
At the conclusion of the session, the participant should be
able to: 1) have a clearer idea of how to proceed with their
careers after residency; 2) describe the fellowship application
process; and 3) demonstrate the ability to discuss practice
and job options.
SUMMARY:
The workshop organizers, who among them have decades of
experience advising senior residents on issues of career
trajectories, lifestyle choices, and post-graduation decisions
51
AMERICAN PSYCHIATRIC ASSOCIATION
Posters
121 thou/mcL and chest radiograph with right sided patchy
opacities in perihilar region. He was admitted to the hospitalist service with diagnosis of community acquired
pneumonia and acute renal failure. Social history revealed
polysubstance dependence, including IV drug abuse prior to
symptoms onset. TTP was suspected and work-up was
started to confirm diagnosis and seek etiology. Methods: TTP
is evaluated in patients with microangiopathic hemolytic
anemia and thrombocytopenia with no other apparent
cause. Patient presentation is diverse, but often includes a
classic pentad of TTP symptoms: microangiopathic hemolytic anemia, thrombocytopenia, neurological symptoms,
renal failure and fever. Testing includes complete blood
count including platelet count, peripheral smear, electrolytes, renal function tests, liver function tests, coagulation
profile, urinalysis. When no etiology is known, new evidence
related to Opana ER abuse by injection recommends
additional information be obtained: asking patient about IV
drug abuse, screening patient for oxymorphone and verifying patient's prescriptions for controlled substances.
Results: Patient had classic pentad of TTP symptoms:
microangiopathic hemolytic anemia, thrombocytopenia,
neurological symptoms (headache), renal failure and fever.
Schistocytes were present on peripheral blood smear. Serum
lactase dehydronase (LDH) was elevated (498 IU/L, reference
range 0-225) and haptoglobin <10 mg/dL (reference range
34-200). Urine drug screen was positive for oxycodone
(oxymorphone), cocaine, cannabinoid and opiate. The
patient volunteered a history of getting his substances from
illicit sources. He used Opana ER by IV TID as his "drug of
choice" 2-3 months prior to admission. Kidney biopsy
confirmed thrombotic microangiopathy. Antiglomerular IgG
membrane antibody, urine legionella antigen, P-ANCA, CANCA, ANA, urine strep. pneumococcal antigen, HIV, rpr,
hepatitis B and hepatitis C screens were all negative.
Coagulation tests were normal. Hematology, nephrology and
psychiatry were consulted. Plasma exchange with fresh
frozen plasma was required as treatment of choice for TTP.
Inpatient substance abuse counseling and treatment was
given. Conclusions: Our case clinically confrims that the
work-up of TTP-like illness of unknown etiology should
include asking the patient about IV drug abuse, of unknown
etiology should include asking the patient about IV drug
abuse, obtaining a urine drug screen for oxymorphone and
obtaining verification of patient's prescriptions for
controlled substances (where available).
POSTER SESSION 1
P1-1
THE MANAGEMENT OF DISRUPTIVE AND POTENTIALLY
VIOLENT PATIENTS ON INPATIENT MEDICAL UNITS
Lead Author: Simona Goschin, M.D.
Co-Author(s): Mary Chandler Rainey, M.D., David Edgcomb,
M.D., Nancy Maruyama, M.D.
SUMMARY: Introduction: The management of disruptive
patients on the medical floors can be very challenging
especially since the staff is not trained to manage this type of
situation. A fast and organized approach is needed and a
clear algorithm for intervention is essential. Case Report: Mr.
F was a 43 y/o man with self-reported history of bipolar
disorder and substance use disorder (opioid, cannabis,
cocaine) who presented several times to the ED after
ingesting pieces of razor blades covered in tape and
endorsing suicidality. After admission he would reveal that
he ingested the razor blade fragments in order to be
hospitalized. He was admitted to a medical floor over a three
day weekend on 1:1 observation. On the medical floor
patient was given hydromorphone for pain. The next day he
was re-evaluated by psychiatry and deemed to be at his
baseline, no longer suicidal and psychiatrically stable for
discharge. The 1:1 was discontinued, but the patient was not
discharged due to lack of social work support for shelter
referral over the three day weekend. The patient was handed
off to a new on-call team which restarted the 1:1. He became
enraged, threatening, shoved a computer which injured a
staff member and then smashed a glass window. A Star Code
(Safety Team Assessment Response) was called and a
multidisciplinary team composed of a psychiatry resident on
call, nurse manager, medicine resident and security guards
arrived and managed the situation. The patient immediately
responded to the intervention, calmed down and apologized
to the psychiatry resident. He was discharged the next day
with the diagnoses of Factitious Disorder, Substance Use
Disorder, possible Malingering and Antisocial Personality
Disorder. Discussion: We present an algorithm developed in
our hospital for intervention in emergent situations when
patients threaten or become violent on medical units. We
describe the training and composition of the team and the
role of the consultation liaison (CL) psychiatrist. We report
some of the characteristics of the patients who have been
seen by CL and the disposition of those patients.
P1-2
IDENTIFYING OXYMORPHONE HYDROCHLORIDE
EXTENDED-RELEASE TABLETS (OPANA ER) INJECTION AS
ETIOLOGY FOR THROMBOTIC THROMBOCYTOPENIC
PURPURA (TTP)
Lead Author: Charles K Dunham, M.D.
Co-Author(s): Sehar Khokher, M.D., Valerie Vestal, M.S.N.,
R.N.
SUMMARY: Background: A 26 year old male presented to the
ED in western North Carolina with 3 day history of
progressive shortness of breath, productive cough (of
yellowish-greenish sputum), chills, sweats, subjective fever
and a four week history of intermittent headache and
generalized malaise. Initial work-up in the ED revealed a
creatinine of 8.95 mg/dL, hemoglobin 8.9 gm/dL, platelets of
P1-3
PSYCHOLOGICAL FACTORS ASSOCIATED WITH CRACK
COCAINE USE IN U.S. GENERAL POPULATION
Lead Author: Andriy Yur'yev, M.D., Ph.D.
Co-Author(s): Xavier Perez, M.D., M.P.H., Willy Philias, M.D.,
Evaristo Akerele, M.D., M.P.H.
SUMMARY: Introduction: Cocaine use disorder is a significant public health issue in the United States which requires
investigation at multidimensional level. The primary source
of information on prevalence of crack cocaine use and its
psychosocial characteristics are qualitative studies. The data
are often skewed since they come largely from individuals
with a diagnosis of cocaine use disorders and those who
present for treatment. In this study the relationship between
52
2014 INSTITUTE ON PSYCHIATRIC SERVICES
psychosocial factors and crack cocaine use in U.S. general
population was explored. Methods: Data from the 29th
General Social Survey (2012) which represents US general
population used for this study. The database includes
individuals who ordinarily would not be captured in most
surveys. It includes a large group of treatment naive
individuals. Questions reflecting to respondents' psychosocial background and crack cocaine use were reviewed.
Chi-square analysis was used to assess relationship between
crack cocaine use and psychosocial factors. Logistic regression was employed to explore complex association between
crack cocaine use and selected psychosocial factors. The
study met criteria for Institutional Review Board exemption
by the Biomedical Research Alliance of New York (BRANY).
Results: In total, 1708 respondents were included in the
study. Among all respondents 6% (N=103) reported lifetime
history of crack cocaine use (8.1% among males and among
4.4% females). Univariate analysis revealed the following
factors are related to crack cocaine use: marital status,
happiness, satisfaction with family and financial situation,
education level, health and crime conviction. Financial
dissatisfaction, unhappiness and criminal history were still
significantly associated with cocaine use in adjustment
analysis. Conclusions: Criminal history, financial dissatisfaction and unhappiness were among key factors associated
with crack cocaine use. The study provides significant
insights that could potentially improve identification,
prevention and management of substance use disorders.
PTSD and Depression in this sample. Anxiety, depression,
and PTSD were not significantly associated with age, gender
or marital status. Conclusions: The political violence
practiced by the Syrian Regime during Syrian conflict
resulted in a high level of psychological traumas. This
represented strongly by the high level of PTSD amongst
Syrian refugees in Syrian- Turkey borders which requires
prompt crisis intervention campaign and urgent
psychological support. Needless to say that further exploring
researches are required.
P1-5
COMPARISON OF CLINICAL FEATURES, IMPULSIVITY
AND TEMPERMENT IN BIPOLAR DISORDER PATIENTS
WHO HAVE COMMITTED CRIME AND NON-COMMITTED
CRIME
Lead Author: Ertugrul Cekic, M.D.
Co-Author(s): Güliz Özgen, Ph.D.
SUMMARY: Bipolar disorder is one of the most interested in
those who research in psychiatry. Clinicians made various
investigations related to crime and temperamental characteristics on patients with bipolar I disorder, but the
temperament characteristics of patients with bipolar
disorder who have committed crime has not been any
research related to the previously. Bakirkoy Psychiatric and
Neurological Diseases Hospital, Forensic Psychiatric inpatient or outpatient observation unit of a crime committed
or the purpose of protection and treatment, and general
psychiatric outpatient clinics or hospitalized in our hospital
and who have received treatment, between 18-65 years of
age, according to DSM-IV criteria for bipolar disorder who
are still in remission, non-judicial criminal record, and
volunteers of the 100 patients enrolled in the study inclusion
criteria. TEMPS-A scale feature of our study hyperthymic
temperament subscale scores were higher (p<0.01), Barratt
impulsivity scale, the motor impulsivity subscale scores were
higher (p<0.05), in patients with bipolar disorder who have
committed crime. In 70 cases (70%) was found in any feature
of temperament. Feature of temperament results were not
statistically significant between the two groups. More homogeneous groups in terms of provision of periods of illness can
provide more contribution to literature. Only a sample
selection of specific sub-groups at crime severity rating scale
can provide more contribution to literature. Work with a
larger sample, can provide more contribution to literature
P1-4
PSYCHSOCIAL SEQUELS OF SYRIAN CONFLICT
Lead Author: M Khaldoun Marwa, D.P.M., M.D.
Co-Author(s): Ibrahim Marwa
SUMMARY: Background: Victims of political violence and
genocide survivors are highly vulnerable to mental and
psychological distress. This study is one of the very few
studies addressed the psychological sequels of Syrian
conflict. Objective: To explore the level of psychological
distress including depression, anxiety, and post -traumatic
stress disorder (PTSD) amongst Syrian Refugees in Syrian
Turkish boarders and associate the level of distress to the
sociodemographic characteristics. Design: A cross-sectional
survey study. Methods: Three hundred surveys were
distributed in four Syrian Refugee Camps located in South
Turkey. Surveys included demographic data, Impact of Event
Scale-Revised (IES-R), and Hospital Anxiety and Depression
Scale (HADS). Snowball sampling method was utilized.
Surveys missing any item were excluded. Data were
processed and analyzed using SPSS v.16s. Frequency Tables
and Chi Square were used. Results: 178 of surveys were
returned, making a response rate of (59.3%). 83 surveys were
excluded due to missing data, and a total of 95 questionnaires were analyzed. The mean age was 34.2 years and the
standard deviation was 11.9 years. 85.3% of respondents
were males. According to IES-R, the prevalence of PTSD
among our sample was 61.1%. According to HADS, 52.6%
had pathologic anxiety, 19.0% were at borderline anxiety
level, 53.7 % were pathologically depressed and 26.3% were
at borderline depression level. There was a strong association with statistical significance between the refugees who
had pathological anxiety symptoms and PTSD (p<0.001),
while there was no statistical significant differences between
P1-6
PERIPHERAL OEDEMA AND ATYPICAL ANTIPSYCHOTICS:
CASE STUDY, REVIEW AND RECOMMENDATIONS
Lead Author: Sam Claude Pang, LL.B., M.B.B.S.
Co-Author(s): Francesca Valmorbida McSteen M.B.B.S., Dr.
Bharat Visa M.B.B.S.
SUMMARY: Peripheral oedema is an uncommon but debilitating side effect of several atypical antipsychotic medications, notably olanzapine, quetiapine, risperidone and
clozapine. A detailed case report of the treatment and
sequelae of a 34-year old man with first episode psychosis
developing severe atypical antipsychotic-induced peripheral
oedema is described. A review of the literature is presented.
Pathophysiological theories are explained. Pharmacological
treatment options include dose reduction, cessation and
switching of the causative atypical antipsychotic medication
and use of diuretics, analgesia and possibly bromocriptine.
53
AMERICAN PSYCHIATRIC ASSOCIATION
physical signs and symptoms, but in addition they also have
a history of recurrent hospitalization, travelling, and
dramatic, untrue, and extremely improbable tales of their
past experiences. There is discussion to reclassify them as
Somatoform disorder in the DSM-5 as it is unclear whether
or not people are conscious of drawing attention to them. A
number of case reports have been published that describe
stereotypic behavior in people with developmental disorders. This is a first case of a kind where we found Factitious
Disorder in context of Asperger Disorder. We learn that
Factitious disorder needs to be suspected in frequent acute
care utilizers with atypical presentations and negative
results. In cases of Aspergers Disorders, patients may not be
able to be diagnosed until after the involvement of the
multiple specialties, invasive work ups, and procedures. The
authors describe a case of Asperger's Disorder where after
the patient had assumed the sick role in the absence of
secondary gain. We present a case report of 16 years old boy
with the Asperger Disorder who was evaluated for the seizure
disorder before he was diagnosed with Munchausen disorder
(Factitious disorder). This case raises the possibility that
other co-morbid disorder can go unrecognized in context of
developmental disorders which could be an important
consideration in certain situations. CASE PRESENATION: 16
year old white teenager boy with history of Asperger
syndrome, Pervasive Developmental Disorder, pseudo
seizure, nystagmus, ingestion of pica transferred from the
other facility after having seizure like activity. Patient was
started on VEEG and Psychiatric C/L services were contacted
for Asperger disease and to r/o pseudo seizure, r/o
Munchausen syndrome. During stay in the hospital he had
an episode of seizure which were characterized by gagging
sound and pooling of saliva in mouth which later he
swallows without any difficulty. Pt refused to take medication orally and wants to have NG Tube for medications. He
also c/o weakness of lower extremities, bilateral with fecal
and urine incontinence and asked for urinary catheter and
diapers respectively. Laboratory workup, imaging and results
of VEEG were normal. Physical and mental status exam
findings were significant for positive nystagmus on eye
contact, hooked with NG tube, urinary catheter and wearing
diaper. Mood was "ok" with anxious affect.
P1-7
CLOZAPINE ASSOCIATED DELIRIUM: A CLINICAL
VIGNETTE
Lead Author: Juliet J. Muzere, D.O.
Co-Author(s): Glenda Wrenn M.D., M.S.H.P., David Purselle
M.D., M.S.
SUMMARY: INTRODUCTION: Clozapine (clozapine) is an
atypical antipsychotic that selectively antagonizes dopamine
D1, D2 and D4 receptors, serotonin 5-HT2 receptors and
cholinergic muscarinic receptors. This second-generation
psychotropic is FDA approved for Treatment-Resistant
Schizophrenia and decreasing the risk of suicidal behavior.
Although highly effective, it does carry serious risks such as
agranulocytosis, seizures, myocarditis, and delirium. Clozapine's side effect of delirium is not widely recognized
however, it occurs in up to 10% of individuals treated with
this medication. The following case report demonstrates this
unique, unfamiliar side effect. CASE DESCRIPTION: A 55
year old Caucasian male with a history of SchizophreniaParanoid Type, Non-Hodgkin's Lymphoma (in remission),
and Parkinson's Disease presented to the psychiatric
emergency room endorsing auditory hallucinations, persecutory and grandiose delusions and ideas of reference. The
patient denied suicidal and homicidal ideation. He reported
adherence to Divalproex ER, Loxapine Succinate, Paliperidone, Citalopram, Trazodone, and Prazosin. He was not
abusing alcohol or drugs. He was admitted to the inpatient
unit for further evaluation and stabilization. Clozapine was
initiated. The projected titration period was 2 weeks with a
goal of 500mg daily. The medication would be titrated by
25mg/day until 200mg was reached and then increased by
50mg/day. The patient endorsed sedation with increasing
dosages of Clozapine but otherwise tolerated the early
titration well. However, at 300mg of Clozapine, the patient
became delirious. Labs and imaging were unremarkable.
Clozapine was reduced from 300mg to 200mg and the
delirium resolved. Clozapine was then slowly titrated over
several days and the psychosis improved. DISCUSSION:
This case illustrates a lesser known side effect of Clozapinedelirium. A few published case reports have described
episodes of delirium following rapid titration of Clozapine.
This was also evident in this particular case. It is imperative
for physicians to be aware of this potential consequence of
Clozapine and to be cautious when using this psychotropic.
Slow titration of Clozapine can reduce the risk of delirium.
P1-10
EMERGING COMPLIANCE ISSUES DUE TO SEXUAL SIDE
EFFECTS OF ASENAPINE
Lead Author: Samina Mirza, M.D.
Co-Author(s): Mahreen Raza, M.D, Najeeb U Hussain, M.D.
SUMMARY: Objective: Since the advent of newer antipsychotic medication with relatively good side effect profile we
are observing quicker and relatively improved symptoms
profile. As it is very well understood that antipsychotic
medications have variety of side effects and specific side
effects correlate with non-adherence. The clearest advantage
of this new atypical antipsychotic is a reduced risk of
extrapyramidal side effect and probably less metabolic
syndromes. The aim of this current study is to examine the
relationship of asenapine or its ingredient with sexual side
effects. It has a unique pharmacologic profile as it targets
multiple dopamine, serotonin and adrenergic receptor
subtypes with variable affinities. Such drug/receptor interactions contribute to the antipsychotic and antimanic
efficacy of asenapine. So far there are no reported cases of
adverse sexual effects of Asenapine. Methods: Case presentation and literature review. We present a case report of
P1-8
WITHDRAWN
P1-9
BRIEF REPORT: FACTITIOUS DISORDER CO-MORBIDITY
WITH ASPERGER SYNDROME, A CRITIQUE
Lead Author: Samina Mirza, M.D.
Co-Author(s): 1. Mahreen Raza, M.D., Najeeb U Hussain,
M.D.
SUMMARY: Asperger disorder was first described by
Australian physician Hans Asperger (1944) as "autistic
psychopathy." Its an uncommon disorder whose exact
prevalence is unknown. Munchausen Syndrome is a psychiatric factitious disorder wherein those affected feign disease,
illness, or psychological trauma to draw attention, sympathy,
or reassurance to themselves. It is also sometimes known as
hospital addiction syndrome, thick chart syndrome, or
hospital hopper syndrome. True Munchausen syndrome fits
within the subclass of factitious disorder with predominantly
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
a similar survey conducted by the author at the same point
in time in the previous year. Students reported levels of
depression, stress, and anxiety far beyond the national
prevalence amongst adults in the United States, and clear
correlations were seen with substance use. Respondents
were more likely to have been diagnosed with ADHD as
adults, and were far more likely to be in treatment with
stimulant medications. The non-medical use of prescription
stimulant medications was also noted, and distinctions in
reported rates of depression, stress, and anxiety between
students diagnosed with ADHD, students without ADHD
who have used stimulant medications, and students who use
high levels of non-prescription stimulants were noted.
patient who developed difficulty in maintaining an erection
after starting the asenapine. CASE REPORT: This is a 47 year
old Jamaican male with a past psychiatric history of Bipolar I
disorder who presented to the ER for his for pneumonia.
Psychiatry is consulted as patient was having sexual side
effects of a relatively new medication, asenapine, two weeks
ago. On evaluation patient was on asenapine 10 mg PO
nightly, started last 2½ weeks ago. He reported that he had
noticed trouble in maintaining an erection. He reported his
manic symptoms have subsided but his erection problem is
giving him embarrassment and anxiety. He requested
change in his medication. The patient had no history of
smoking, alcohol consumption, any other associated
pathology or concurrent drug intake. He denied any history
of physical or sexual abuse. There was no history of such an
episode in recent past or any medication allergy. Asenapine
discontinuation resulted in improvement of his erectile
dysfunction. CONCLUSION: This case not only provides
additional information about a potential new side effect of
asenapine usage, but also enables clinician to foresee
potential obstacle in medication compliance, which would
be essential for better management of psychiatric illness. It is
also studied and validated by Naranjo scale as the side effect
of asenapine.
P1-13
THE ESTABLISHMENT OF A MULTIDISCIPLINARY CLINIC
FOR ADULTS WITH 22Q11.2 DELETION SYNDROME AND
THEIR FAMILIES - WHY, HOW, AND OUTCOMES
Lead Author: Wai Lun Alan Fung, M.D., S.M., Sc.D.
Co-Author(s): Anne S. Bassett, M.D., F.R.C.P.C.
SUMMARY: The 22q11.2 Deletion Syndrome (22q11.2DS) is
the most common genomic disorder in humans, affecting 1
in every 2000-4000 live births. Its complex and multisystemic
clinical manifestations—including various psychiatric issues
in many cases such as anxiety, mood and psychotic
symptoms—make the provision of comprehensive care for
patients challenging. A coordinated, multidisciplinary team
approach is instrumental to the provision of efficient and
effective care to these patients. The Dalglish Family Hearts
and Minds Clinic at Toronto General Hospital, Toronto,
Ontario, Canada was established in 2012 as the world's first
comprehensive, multidisciplinary clinic fully dedicated to
adults with 22q11.2DS and their families. Directed by two
psychiatrists experienced in the care for adults with
22q11.2DS, the Clinic offers a unique program of "one-stop
shopping" for these patients and families, with medical
professionals from a variety of specialties as well as allied
health professionals (psychology, social work, nursing,
dietetics, etc.) working together interprofessionally. This
poster presents the establishment and refinement of the
service model, as well as various measures of patient
outcome and quality of care. This Clinic could serve as a
model for other clinics dedicated to adults with 22q11.2DS,
and potentially to adults with other emerging genomic
disorders.
P1-11
DEPRESSION SCREENING IN PARKINSON'S DISEASE
PATIENTS UNDER-GOING EVALUATION FOR DEEP BRAIN
STIMULATION THERAPY, ONE CENTER'S EXPERIENCE
Lead Author: Sureshkumar H Bhatt, M.D.
Co-Author(s): Georgia Lea, M.D.
SUMMARY: Introduction: This is a retrospective study of a
total of 96 patients who had STN-DBS implantation at
Ochsner 2006-2011 for the treatment of Parkinson's disease.
The purpose of this review was to determine whether or not
patients were being adequately screened for depression prior
to surgery as presence of depression can affect outcomes.
Method: Medical records were reviewed for documentation
of depression screening, presence of depression and other
psychiatric problems. Results: Only 19% of patients had
documentation of depression screening prior to surgery.
Conclusion: A significant practice gap was revealed by this
chart review and has now resulted in standard screening
with the Geriatric Depression Scale-Short Form which will
now be included in all pre-surgical evaluations for DBS at
Ochsner.
P1-14
CASE REPORT OF IMPROVED ADHERENCE WITH
PSYCHIATRIC COLLABORATION IN PRIMARY CARE
Lead Author: Ernest A Gbadebo-Goyea, M.D.
Co-Author(s): Uzoma C. Oranu, M.D.; Yetunde Olagbemiro,
M.D., M.P.H.; Schola A. Nwachukwu, M.D., Joanna E. T.
Shaw, M.D.
SUMMARY: Introduction: Tuberculosis (TB) continues to be
a major public health problem worldwide. The World Health
Organization (WHO) estimates that 8.7 million people became ill from TB and 1.5 million died from TB in 2011. The
Center for Disease Control and Prevention (CDC) reports
that 10,528 people were diagnosed with TB in the USA.
People with disabling mental disorders are more at risk for
certain health problems including communicable diseases
such as TB. Untreated mental illness is a barrier to care and
treatment adherence. Case description: A 60-year-old Cambodian female with a medical history significant for hepatitis
C and schizophrenia was involuntarily admitted to the
P1-12
DEPRESSION, STRESS, AND ANXIETY AMONGST
MEDICAL STUDENTS IN THE FINAL MONTH OF THEIR
PRECLINICAL EDUCATION
Lead Author: Robert Rymowicz, B.Sc.
SUMMARY: Many medical students feel that the final month
of class during their second preclinical year is amongst the
most difficult and exhausting they have ever experienced, as
they must concern themselves with both final exams and
boards, and their performance may well determine the
course of their future careers in medicine. Students at a
medical college in Southern California were asked to complete an anonymous online survey. Self-reported responses
to multiple choice questions were collected and analyzed
both in the aggregate and with respect to specific subgroups.
To protect anonymity and encourage honest reporting,
personal information other than gender was not requested.
Some longitudinal analysis was possible, using the results of
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AMERICAN PSYCHIATRIC ASSOCIATION
hospital by the Health Department due to non-adherence
with management of her pulmonary TB. Pt. was resistant to
multiple referrals to psychiatric services for evaluation &
management of her psychiatric illness. One year ago prior to
presentation, she developed a productive cough. She denied
fevers, night sweats, or weight loss. Evaluation at the Health
Department revealed a highly reactive PPD and cavitary
lesions on chest x-ray. Rifampin, Isoniazid, Pyrazinamide,
Ethambutol (RIPE) and Pyridoxine therapy were initiated.
The patient was non-adherent to medical follow-up despite
elevated liver enzymes at the health department. Therefore,
she was involuntarily admitted to the hospital. During
hospitalization, she continued to be uncooperative with
medical treatment and blood draws. The family admitted
that the patient had been isolative, experiencing auditory &
visual hallucinations, paranoia, and fear of people for several
months. These psychiatric symptoms continued during
hospitalization. The psychiatric service was consulted to
address patient's untreated psychiatric illness. Psychotropic
medications were commenced to target reported symptoms.
Within 5 days, the patient's mood and behavior improved;
she permitted medical treatment. At a court hearing, the
judge found her to be mentally stable and adhering to
therapy. She was discharged home with family and
instructed to follow-up with the health department and the
psychiatric clinic. Discussion: People with mental disorders
are targeted by the CDC for enrollment in DOT programs.
Our case is important in showing that DOT alone is not
adequate in people who have mental illness and a multidisciplinary approach to their care is needed. Given that a
vast number of people with mental illness have other
comorbid conditions seen in primary care, it is important
that mental health status be documented and addressed by
TB treatment providers, Appropriate consultation with
mental health providers be sought in order to adequately
treat psychiatric symptoms that potentially could hinder
treatment compliance given the nature of most psychiatric
illness who may not recognize their own health problems or
may be distrustful of the healthcare system.
and being referred as a psych patient. Once she was at
baseline she was discharged home from ED. Catatonia:
Catatonia is a state of neurogenic motor alterations and
behavioral abnormalities that occurs in the context of
medical and psychiatric disorders. The true pathogenesis of
catatonia remains unclear but pathways involving basal
ganglia, cortex and thalamus play a role as well as a decrease
in D2 receptors, decreased GABA-A binding and hyperactivity at N-Methyl-D aspartate receptors. Awareness
during catatonic state: Literature describing the state of
awareness during a catatonic episode is sparse. One study
showed decreased glucose metabolism on PET scan in areas
responsible for behavior, motor initiation and centers of
awareness, leading to the conclusion that in catatonia
awareness is decreased or absent. Meanwhile a case report
mentioned the use of Bi-Spectral (BIS) monitor in a catatonic
patient demonstrating a state of wakefulness. No large
studies or more extensive findings were evident during
literature review. Discussion: Catatonia is well recognized in
the psychiatric community, but still both its pathophysiology
and psychological aspects remain unknown. For patients
that report awareness during a catatonic episode the experience may be frightening and actions surrounding their
management may produce increased anxiety and disrupt our
therapeutic alliance. It remains unclear if all or just some
patients experience awareness, but this may also go
unreported. Investigation shows limited studies in this
subject which would yield a better understanding into
catatonia and its treatment.
P1-16
ACUTE DYSTONIA AND BRUXISM WITH SERTRALINE
TREATMENT: A CASE REPORT AND LITERATURE REVIEW
Lead Author: Meredith M Brandon, M.D.
Co-Author(s): Giovanni Caracci, M.D., Rashi Aggarwal, M.D.
SUMMARY: Background: The selective serotonin reuptake
inhibitors have become the most widely prescribed antidepressants in the United States. Although SSRIs are generally
better tolerated than other antidepressants such as tricyclic
antidepressants and monoamine oxidase inhibitors, they are
associated with some notable side effects. Less well known,
yet clinically significant, are movement disturbances that
can occur with SSRI use. Case: We present a case involving
the development of an acute dystonic reaction and bruxism
after 7 days of treatment with 50mg of sertraline and then an
increase to 75mg for one day. The case involves a 22-year old
male with no previous psychiatric history and no significant
medical history who was admitted to the hospital for
treatment of a major depressive episode after attempting
suicide by cutting his wrist. Upon initial evaluation, patient
reported severe depressive symptoms including insomnia,
poor appetite and concentration, anhedonia, and feelings of
hopelessness and worthlessness. He denied being treated
with any psychotropic medications in the past. He was
started on sertraline 50mg daily only, which was titrated up
to 75mg daily the day before discharge for continued
complaints of low motivation and energy. On the day of
discharge, he began complaining of bruxism (teeth grinding
and jaw clenching) and acute neck dystonia. He was administered 25mg of diphenhydramine and both symptoms had
resolved over the course of an hour. Discussion: In this case,
sertraline was implicated as the cause of the bruxism and
acute neck dystonia as the patient was not treated with any
other psychotropic medications throughout his hospitalization. SSRIs appear to be more frequently associated with
P1-15
AWARENESS DURING CATATONIA: HOW AWARE ARE WE?
Lead Author: Michelle Benitez, M.D.
SUMMARY: Awareness during catatonia: How aware are we?
Introduction: Catatonia is a known behavioral syndrome
that presents in medical and psychiatric disorders. But little
is known about patients’ awareness and their subjective
exper-ience during a catatonic episode. Here we present a
case of a 52 year old woman with diagnosis of Bipolar
disorder, who presented to the Emergency Department (ED)
in a catatonic state. After patient returned to her baseline she
recounted her experience during the episode describing fear,
pain and frustration with management. Case: A 52 year old
woman with past history of bipolar disorder, presented to
the ED in a catatonic state she arrived in stupor, in a fixed
posture with extension of both arms and occasional grimacing. She was administered 2 mg of lorazepam IV, and
returned to baseline. The day before admission, patient went
to bed and described being unable to wake up or open her
eyes and unable to move. Patient recalls EMT entering her
room, and described feeling pain during the sternal rub. She
also described the foul smell of the intranasal salts used in an
attempt to wake her up. She recalls some of the painful
maneuvers repeated in ED, but stated the most frustrating
part was hearing staff speak about her "faking" the episode
56
2014 INSTITUTE ON PSYCHIATRIC SERVICES
EPS than other antidepressants. They are not dose related
and can develop with short-term or long-term use. In our
case, however, it appears that EPS occurred as a result of an
increase in the dosage of sertraline by only 25mg. Pathophysiologic mechanisms of SSRI-induced movement
disorders are not well established, but most data suggests
that the agonism of sertonergic input to dopaminergic
pathways within the CNS is the most probable cause for
SSRI-induced EPS. Conclusion: Antidepressants are meant
to improve the quality of life of patients. Therefore, it is
essential that prescribers are aware of all potential side
effects and closely monitor patients as movement disorders
are uncomfortable, can adversely impact adherence, and can
undermine the alliance between clinician and patient.
P1-18
TRANSFORMING FRUSTRATION INTO POSSIBILITY: A
MODEL FOR UNDERSTANDING AND NAVIGATING
COMPLEX SYSTEMS IN A CHANGING LANDSCAPE
Lead Author: Madeleine S Abrams, L.C.S.W., M.S.W.
Co-Author(s): Nicole Allen M.D., Joseph Battaglia M.D., Adi
Loebl M.D., Jeffery Lucey M.D., Ingrid Montgomery, M.D.,
M.P.H., Daniel Patterson, M.D., Sarah Quinn Ross, M.D., Ayol
Samuels, M.D., Andrea Weiss, M.D.
SUMMARY: Multiple complex systems are involved with
people diagnosed with serious mental illness. At a time of
rapid transitions in healthcare reform, consumers, family,
staff, and trainees often feel powerless to have an impact.
Healthcare providers are expected to navigate multiple
systems of care that function separately and, frequently, in
opposition to each other. The challenges they confront
include understanding the overall healthcare delivery
system; advocating for individuals who feel disempowered
when the treating person shares similar feelings; managing
those who have been and continue to be involved with the
forensic system; confronting ethical dilemmas of beneficence versus autonomy; and dealing with pain, anger, and
hopelessness of families who must cope not only with
mental illness itself but also with their failure to have an
impact on treatment. Further, as the integration of medical
and psychiatric services becomes the standard of care,
collaboration and negotiation between medical and mental
health providers in the medical home model is essential. As
the recovery and medical home models become more
prominent, the ability to operate effectively within complex
systems is increasingly important for clinicians working with
people with serious mental illness, especially in the public
sector. While some clinicians become activated to develop
creative interventions and become committed to working
with this population, others feel overwhelmed, fearful, and
hopeless. Since what occurs at higher levels is felt throughout the organization, providing education and a forum for
discussion about systems issues for staff and trainees will
have an effect on their ability to advocate for consumers and
families. Psychoeducation is an evidence-based treatment
modality that focuses on learning to live effectively with
serious mental illness by providing information about the
illness and teaching skills for management. In parallel to that
model, we propose that treatment personnel are empowered
by understanding how systems work, knowing who is
involved in the decision-making process, how to understand
the obstacles to solutions, and how to access available
resources. To that end, we have developed a model for
training about systems based care in the new healthcare
environment.
P1-17
DIGEORGE SYNDROME AND ITS NEUROPSYCHIATRIC
MANIFESTATIONS: A CASE REPORT
Lead Author: Jose A. Alvarez, M.D.
Co-Author(s): Asim Risvi M.D., Jose Arturo Sanches LAcay
M.D., Ayme Frometa, M.D., Dora Isabel Duque, M.D.,
Maria Reynoso, M.D.
SUMMARY: Background: There is a high incidence of psychiatric symptoms in patients with DiGeorge syndrome. We
present a patient with DiGeorge syndrome who had
decompensated with aggression and hyperactivity, to educate healthcare providers about management and treatment
options when this correlation is present. Methods: We
reviewed the case of a 7.3 year-old Hispanic Female who
presented to the Emergency Department with physical
aggression, hyperactivity, suicidal statement without plan,
self- mutilation, with a history of DiGeorge syndrome diagnosed in infancy and Oppositional Defiant Disorder and
Attention Deficit Hyperactivity Disorder since the age of 5.
Results: In the unit, patient continued to display cantankerous and irascible behavior, hyperactive, defiant, in need of
limit setting, almost constantly, especially at the beginning
of hospitalization. Her behavior continued to be unpredictable and her medications continued to be titrated. Pt was
referred to a nutritionist where Pediasure was recommended
3 times a day to improve nutritional status and she was
maintained on methylphenidate 5 mg per os three times
daily. Discussion: The DS22q11.2 syndrome can have very
high rates of psychiatric morbidity and abnormal behaviors.
Psychiatric manifestations of the illness tend to start in
childhood. Afflicted children with this gene tend to be shy,
withdrawn, stubborn, emotionally labile, and suffer from
social and communication impairments. Children and
adolescents with DS22q11.2 have a high rate of nonpsychotic psychiatric disorders such as Attention Deficit
Hyperactivity Disorder, Oppositional Defiant Disorder,
Anxiety disorders, affective disorders, and Autism Spectrum
disorders. Conclusion: Assessment of DiGeorge syndrome
should include psychiatric assessment, to identify the need
of medical management, as it has a high correlation with
psychiatric illness. Cognitive assessment can be followed
with IQ testing and psychological awareness with family
members, school teams, and healthcare providers.
References:
P1-19
RECURRENT IDIOPATHIC CATATONIA: RELIGIOUS
CURSE OR MEDICAL MALADY.
Lead Author: Abhishek Rai, M.D.
Co-Author(s): Lakshit Jain, M.B.B.S., Fadi Georges, M.D.,
Vishal Chhabra, M.D., Ishita Singh, M.B.B.S.
SUMMARY: Introduction: Periodic catatonia is a less
commonly encountered, but puzzling diagnosis [1]. Idiopathic periodic catatonia can be a difficult disease for the
patient, the family members and the treating psychiatrist.
Stigma to mental health and religious beliefs can make
treatment compliance worse. Case report: We present a case
of 33 year old Asian, single male presented with complaints
1) The Diverse Clinical Features of Chromosome 22q11.2 Deletion
Syndrome (DiGeorge Syndrome) Maggadottir SM, Sullivan KE. J Allergy
Clin Immunol Pract. 2013 Nov-Dec;1(6):589-94.
2) The spectrum of the DiGeorge syndrome. Conley ME, Beckwith JB,
Mancer JF, Tenckhoff L.
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AMERICAN PSYCHIATRIC ASSOCIATION
development or may cause neuronal death. Researchers
hypothesize that drug metabolites interact with the genetic
makeup to influence cognitive development and behavior.
Hence prenatal exposure of foreign agents like Nicotine/
tobacco, alcohol, cocaine, drugs etc may have an adverse
effect on the central nervous system (CNS) of the developing
fetus and subsequently reflect later in a child's neurobehavioral function. Objective: The purpose of this review
was to examine the literature assessing the relationship
between prenatal exposure of illicit drugs and medications to
the risk of developing ADHD in childhood. Method: We are
conducting a literature review from previous articles through
Pub med and other resources. Result: studies have shown
cigarette smoking, alcohol, marijuana, cocaine, methylphenidate, atomoxetine, methamphetamine, acetaminophen, antiepileptics and antihypertensives used during
pregnancy have an increased risk of ADHD in children.
Conclusion: With the growing concern regarding ADHD, all
drugs, including prescribed medications should be avoided
during pregnancy. Women who wish to use prescribed drugs
during pregnancy should be assessed to determine whether
the potential benefits to the mother outweigh any risk to the
fetus. Behavioral interventions with close monitoring should
be encouraged in the clinical setup as the first treatment
option to help pregnant women abstain from illicit drug use.
of mutism, refusal to eat or drink and a complete lack of
activity. His family reported multiple episodes over an 8 year
period. On his first instance, patient responded well to high
dose lorazepam IV. Liver and renal function tests, thyroid
function, EEG, MRI revealed no organic cause of catatonia.
On tapering the dose of lorazepam patient had a relapse and
presented again with similar complaints in 3-4 months. An
exhaustive history taken for psychiatric symptoms revealed
nothing and no family stressors could be identified. Patient
did not respond to high dose IV lorazepam and a decision to
start ECT was taken. Patient responded at 3rd ECT and
further 7 ECTs were admistered. Patient was again discharged on 12mg oral Lorazepam. Later patient complained
of sedation during the day and requested decrease in his
lorazepam dose. Meanwhile patient's family also did a religious ritual named "Pitr Puja" to appease the souls of elders
who died heirless. Despite a close follow-up, patient had a
3rd relapse after tapering the dose of oral lorazepam. With a
failed ritual and severely injured moral behind them the
religious belief of the family clouded and overwhelmed there
better judgment beyond counseling. They sought patients
discharge against medical advice and the patient was lost to
follow up. Discussion: Even after intense effort the etiology
remained elusive, leading to the diagnosis of idiopathic
periodic catatonia. With medical advancement atypical antipsychotics and NMDA antagonist are also being tried for this
disease, albeit with caution (2). Yet periodic catatonia
remains stressful condition for the patient and the family.
When medicine with its limited scope disappointed them,
they desperately turned to religion which led to gross
incompliance to treatment. The religious belief's blindfolded
them to imminent peril and it ultimately led to the loss of the
patient to the follow-up. CONCLUSION: Cases like this draw
our attention to the fact that idiopathic psychiatric disorder
need effective counseling of the patient and caretakers with
ought which whole institution of medicine and patient care
can be crippled by the throttlehold of religion and mental
health stigma in the society.
References:
P1-21
MAJOR DEPRESSIVE DISORDER: A CASE OF AN ADOLESCENT FEMALE WITH RUSSELL-SILVER SYNDROME
Lead Author: Muhammad Puri, M.D., M.P.H.
Co-Author(s): Monica Badillo
SUMMARY: Russell-Silver Syndrome (RSS) is congenital
genetic disorder characterized by aberrations in genes that
control growth and development. This syndrome may result
from a maternal uniparental disomy of chromosome 7
(matUPD7); this means that the child inherits two copies of
chromosome 7 from the mother instead of one from each the
mother and the father. Another cause is imprinting; this is
the hypomethylation of chromosome 11p15 where only the
copy of the gene inherited from the father is expressed (3).
The genes known to be affected are H19 and IGF2 (7). The
H19 genotype has phenotypic correlations with skeletal
abnormalities such as scoliosis (9). The matUDP7 defect
accounts for 10% of cases and the imprinting of chromosome 11 accounts for more than 38% of cases (3). Other
chromosomes that may be involved include 1, 7, 14, 15, 17,
and 18 (8). Most cases of RSS are sporadic but some display
an autosomal dominant inheritance pattern (7). One in
75,000 to 100,000 people are affected and distributed equally
between men and women (7, 5). The management of RSS is
dependent on the clinical presentation and symptoms. RSS
may be treated with growth hormone, physical therapy,
speech and language therapy, glucose monitoring, antacids,
and dietary supplementations (9). What happens when this
diagnosis of Russell-Silver Syndrome in an adolescent is
complicated by the psychiatric diagnosis of Major Depressive Disorder? The purpose of this case report is to discuss
an adolescent patient with Russell-Silver Syndrome presenting with Major Depressive Disorder associated with psychotic features. The focus of the case will be management of
MDD in conjunction with the physical ailments of RSS. The
method used was a literature search of PubMed and Google
on the topics of RSS, AS, MDD, and pertinent medications.
[1] Fink M, Taylor MA; the catatonia syndrome: forgotten but not gone;
Arch Gen Psych 2009; 66:1173-77
[2] Hervey WM, Stewart JT, Catalano G; Diagnosis and management of
periodic catatonia; J Psychiatry Neurosci. 2013 May; 38(3):E7-8
P1-20
ILLICIT DRUG AND MEDICATIONS USED IN PREGNANCY
CAUSES ADHD
Lead Author: Muhammad Asif, M.D.
Co-Author(s): Asif M, Nadeem A, Zheung S, Duwaik S, Asghar
H
SUMMARY: Abstract: Background: Attention deficit hyperactivity disorder (ADHD) is a common childhood neuropsychological disorder characterized by symptoms of
inattention, hyperactivity and impulsivity that are not
appropriate for a person's age and later in life, are at an
increased risk of conduct disorder, antisocial behavior and
drug abuse. The worldwide pool prevalence was 5.29% and
70% of the children with ADHD continue to have symptoms
as adults. The cause of most cases of ADHD is unknown;
however, it is believed to involve interactions between
genetic and environmental factors in a polygenetic pattern
so that genes can exert their influence only via interactions
with the environment. It is known that active metabolites of
drugs enter the fetal bloodstream and penetrate the fetal
blood-brain barrier interfering with early neuronal cell
58
2014 INSTITUTE ON PSYCHIATRIC SERVICES
may be a significant cause to an increased risk of suicide.
Objective: Estrogen plays a key role in modulating impulsive
and aggressive traits in patients suffering from leiomyoma.
Our goal is to determine the correlation between estrogen
and aggression to aim for the recognition and understanding
of estrogen leading gynecological conditions e.g. leiomyoma
and its impact on mental health. At the conclusion of this
session the participants should be able to recognize the
relationship and mechanism behind excess estrogen
secretion, the serotonergic system and depression-anxiety.
Early detection is of paramount importance for the quality of
life of these patients. Method: We are conducting a literature
review from PubMed and other resources along with a case
report.
P1-22
CARING FOR TRANSGENDER AND GENDER NONCONFORMING PATIENTS IN THE INPATIENT SETTING
Lead Author: Michael B Leslie, M.D.
Co-Author(s): Kevin M. Donnelly-Boylen, M.D.
SUMMARY: BACKGROUND: Transgender and gender nonconforming individuals face many disparities in the delivery
of healthcare. This population faces a disproportionate rate
of psychiatric comorbidity, including suicide attempts, that
can necessitate inpatient psychiatric care. At the same time,
many transgender people are apprehensive about receiving
mental health care due to psychiatry's complicated, and not
always supportive, position with regards to gender identity.
CLINICAL CHALLENGE: The inpatient care of transgender
patients presents challenges related to varying levels of staff
cultural competence, complex team dynamics, and unforeseen practical considerations in accommodating unit and
patient needs. A paucity of research exists to help guide
inpatient clinicians and administrators in providing care for
this vulnerable and under-served population. DISCUSSION:
This poster reviews key vocabulary and major concepts in
transgender mental health. It describes common challenges
that arise in the inpatient care of this population. We
propose recommendations for the inpatient management of
transgender patients based on current treatment guidelines.
These will include suggestions for initial assessment,
addressing administrative challenges, and ways in which
interdisciplinary staff can be united in their approach to
care. We identify areas for potential research that would
guide the care of this patient population.
P1-24
THE AWAKENINGS PROGRAM TO REDUCE UNNECESSARY MEDICATIONS IN LONG TERM CARE: RESULTS OF A
THREE YEAR PERFORMANCE BASED INCENTIVE
PAYMENT PROGRAM STUDY
Lead Author: Tracy A Tomac, M.D.
Co-Author(s): Maria Reyes, R.N.
SUMMARY: The Awakenings program is a comprehensive
dementia care program in place at 15 skilled nursing
facilities (1219 beds) in the Ecumen care system in Minnesota. Goals of this program include improving quality of life
of residents, reducing unnecessary medications, and
improving quality of care through culture change. In 2010
Ecumen was awarded a three year $3.8 million Performance
Based Incentive Payment Program (PIPP) grant by the
Minnesota Department of Human Services (DHS) to implement Awakenings. The results of the three year study period
(2010-2013) are now finalized, and Awakenings achieved the
goals set in the PIPP grant. The primary outcome measure
was the Minnesota Quality Indicator "Prevalence of Antipsychotics without a Diagnosis of Psychosis." Compared to
baseline, each quarter of the three year study period showed
approximately 90% improvement in QI scores. The second
measure involved the DHS Quality of Life survey, with a goal
of 6% improvement over the three year period met by the
program. Awakenings relies on involvement of residents,
families, facility management, and the entire multidisciplinary treatment team. This presentation will outline the
steps involved in the program and present the study results.
P1-23
ESTROGEN/LEIOMYOMA AND ITS EFFECT AND
CORRELATION WITH AGGRESSION
Lead Author: Syed E Maududi, M.D.
Co-Author(s): S. Maududi, MD, Atifa Nadeem, MD, Asghar
Hossain, MD
SUMMARY: Introduction: Uterine leiomyoma (UL) is the
most prevalent benign gynecological smooth muscle tumor.
From 100 women, 80 present with UL and of which 30% are
symptomatic. Growth of UL has great to do with estrogen
and progesterone. It is believed that increased estrogen
sensitivity promotes growth by up-regulating IGF-1, EGFR,
TGF-beta1, TGF-beta3 and PDGF, and promotes aberrant
survival of leiomyoma cells by down-regulating p53,
increaseing expression of the anti-apoptotic factor PCP4 and
antagonizing PPAR-gamma signaling. On the other hand
progesterone counteracts the growth. Symptomatic UL
present with heavy or painful menses abdominal discomfort
or bloating, painful defecation, back ache, urinary frequency
or retention, and in some cases, infertility. Psychologically it
causes aggressive, antisocial behavior and violence. A correlation has been thought to exist between estrogen and these
psychological findings. In a similar pattern other estrogen
promoting gynecological disorders may also present with the
same psychological behaviors. Estrogen modulates anxietydepression behavior (impulsive-aggressive traits) by regulating the serotonergic system by selectively increasing TPH
mRNA expression in the midbrain promoting the synthesis
of serotonin which is a pivotal neurotransmitter in the
regulation of mood and behavior. Proper monitoring of
estrogen related gynecological disorders is important for the
early detection of behavioral changes as impulsiveaggressive traits are a part of a developmental cascade
increasing the risk of suicide. A leiomyoma left untreated
P1-25
MAJOR DEPRESSIVE DISORDER IN PRIMARY CARE
VERSUS MENTAL HEALTH
Lead Author: Chandresh Shah, M.D.
SUMMARY: Depression has many faces and it presents as
various concerns and complaints. Patients seeking help for
depression were either self-referred to mental health (MH) or
referred by primary care providers (PC). These patients were
given Beck Depression Inventory (BDI) along with psychiatric mental status examination. There were 19 PC patients
with major depressive disorder; 11 males (age=58.02+/-11.18
years) and 8 females (age= 55.83+/-13.31). There were 23 MH
patients with major depressive disorder; 12 males
(age=57.46+/-12.23 years) and 11 females (age= 50.11+/9.74). The total BDI score reported by MH was 29.91+/-9.11;
higher than that reported by PC which was 22.12+/-10.17
(P<0.05). Similarly the BDI severity score was also reported
higher by MH (2.89+/-0.91) as compared to that by PC of
2.48+/-1.01 (P<0.05). Sad mood was the universal symptom
reported by all, 100% of patients in both groups PC and MH.
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AMERICAN PSYCHIATRIC ASSOCIATION
P1-28
FROM SURVIVING TO ADVISING: PAIRING MENTAL
HEALTH AND ADDICTION SERVICE USERS AS ADVISORS
TO SENIOR PSYCHIATRY RESIDENTS
Lead Author: Sacha Agrawal, M.D., M.Sc.
Co-Author(s): Pat Capponi; Sean Kidd; Rebecca Miller;
Charlotte Ringsted; Jenna Robinson; Sophie Soklaridis; David
Wiljer
SUMMARY: Achieving the goal of a recovery-oriented
behavioral health system requires a shift in postgraduate
psychiatric education to engender among trainees a more
person-centered stance toward people living with mental
health and addiction issues. This project aims to develop a
novel model for postgraduate psychiatric education that
pairs mental health and addiction service users as advisors to
psychiatry residents to (1) enable residents to learn more
deeply about the lived experience of people with mental
health and addiction issues outside the confines of the
doctor-patient relationship, (2) reduce prejudice among
residents, and (3) empower service users. Eighteen pairs are
meeting monthly from January to June 2014. Advisees
consist of the full cohort of University of Toronto fourth year
psychiatry residents assigned to the chronic care rotation.
Advisors were selected for communication skills and experience in peer support or advocacy and receive a stipend and
monthly group supervision. The experience of all participants will be explored qualitatively through on-line
reflections as the relationship unfolds and in-depth individual interviews at its completion. A phenomenological
analysis will be applied to the data, the results of which will
be presented. Key issues that have surfaced thus far are the
need to focus on organizational and learner buy-in; the
complexity of space, time and boundaries in defining these
relationships; and the centrality of trust as a critical
ingredient for learning.
Other top 10 symptoms in PC were mostly somatic - Fatigue,
Loss of Energy, Changes in Sleep and Appetite, Loss of
Interest in Sex, Concentration Difficulty, Indecisiveness, Loss
of Pleasure and Interest. In contrast, other top 10 symptoms
in MH were mostly psychic Loss of Pleasure and Interest,
Worthlessness, Changes in Sleep, Crying and Irritability,
Pessimism, Guilty Feelings, Suicidal Thoughts. PC reported
higher severity of Fatigue, Change in Sleep, Loss of Interest
in Sex and Suicidal Thoughts. MH reported higher severity
for Crying, Pessimism, Worthlessness and Self-dislike.
Suicidal thoughts were reported by more MH (47.82%) as
compared to By PC (21.05%); (P<0.005). But severity of score
for suicidal thoughts was higher in PC (2.01+/-1.23) as
compared to that in MH (0.97+/-0.89); (P<0.001). It is
interesting to note difference in prevalence and severity of
symptoms of major depressive disorder among PC and MH.
It is important to note that suicidal thoughts in PC were
reported less frequently but more severely. Patients with
major depressive disorder may present with different
priorities in their need for relief and resolutions of their
suffering.
P1-26
PTSD AND QUALITY OF LIFE AMONG IRANIAN EXPRISONERS OF WAR
Lead Author: Nazanin Vaghari Mehr, M.D.
Co-Author(s): Saeed Momtazi, M.D.
SUMMARY: Introduction: Being captured as prisoner of war
is one of the most stressful experiences for all people. During
eight year Iran-Iraq war tens of thousands Iranian veterans
had such experience. In this study we aimed at assessing
Iranian ex-prisoners of war for PTSD and quality of life.
Methods: Our group consisted of 132 ex-prisoners of war.
The participants were selected using a random sampling.
The mean age of the participants of our study was 45.9 years.
We used PCL-M questionnaire for PTSD and WHOQOL
questionnaire for quality of life. Results: Among POWs 57/7%
have shown good quality of life. According to PCL-M results
36% of POWs had PTSD. PTSD had association with poor
quality of life and higher smoking rate, but the age, duration
of captivity and their current job had no relation with PTSD.
Conclusions: There is high prevalence of PTSD and poor
quality of life among Iranian ex-prisoners of war.
P1-29
ADVERSE OUTCOME OF PSYCHIATRIC INTERVENTIONS:
RESULTS FROM A SYSTEMATIC REVIEW
Lead Author: Bauke Koekkoek, Ph.D.
SUMMARY: Background/Objectives: In medicine and
psychiatry adverse outcomes of biological interventions (e.g.
psychopharmacological medication) are widely researched
and documented. However, much less attention is paid to
such outcomes of psychotherapeutic and “particularly“
psychosocial interventions such as hospital admission,
intensive home or community treatment, and long-term
supportive care. Adverse outcomes may include, but are not
limited to, physical harm to self or others, loss of social
functioning, and long-term dependency on services and
others. Since we know little of these outcomes, the following
research questions were stated: 1) what are adverse outcomes of non-biological and non-psychotherapeutic treatments in psychiatry and mental health services, 2) what
types of causes are recognized for these adverse outcomes, 3)
what are the known chances (risks) of the occurrence of
these adverse outcomes? Methods: Systematic review in
which search terms from three groups (adverse outcomes,
psychiatric treatment, and psychiatric disorders) were
combined. Additional search strategies were applied to
detect specific adverse outcomes. Results: The larger part of
research on adverse outcomes is done on biological
interventions, a much smaller part on psychotherapeutic
interventions, and an even smaller part on psychosocial
interventions. Adverse outcomes vary from minor incidents
P1-27
ADOLESCENT SUICIDE PACTS AND THEIR IMPACT ON
THE COMMUNITY
Lead Author: Andrea M Brownridge, J.D., M.D., M.H.A.
Co-Author(s): Michael Shapiro, M.D., Mathew Nguyen, M.D.
SUMMARY: While suicide is the third leading cause of death
for young people (aged 15-24 years), statistically speaking it
is a rare event. In 2010, 4600 youth aged 15 to 24 died by
suicide, resulting in a suicide rate of 10.45 per 100,000. The
top three methods used in suicides of young people include
firearms (45%), suffocation (40%), and poisoning (8%).
Suicide pacts are much rarer and are documented very
infrequently in the literature. There is little to suggest why a
single suicide creates a contagion effect, as most suicides are
"self-contained" events that do not spread. We will examine
the case of a community in which there were two completed
suicides and then nearly a dozen attempts leading to
psychiatric hospitalization.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
P1-31
CHARACTERISTICS OF PATIENTS WITH SCHIZOPHRENIA
TREATED WITH ANTIPSYCHOTICS IN COMMUNITY
BEHAVIORAL HEALTH ORGANIZATIONS- REACH OUT
STUDY
Lead Author: Kruti Joshi, M.P.H.
Co-Author(s): Lian Mao, Ph.D.; Carmela Benson, M.S.; Jessica
Lopatto, Pharm.D.; David Biondi, D.O.; John M. Fastenau,
R.P.H., M.P.H.
SUMMARY: Objective: The aim of this analysis was to
compare characteristics of patients with schizophrenia
receiving atypical long-acting injectable (LAI) or oral
antipsychotic treatment (OAT) in community behavioral
health organizations (CBHO). Methods: The Research and
Evaluation of Antipsychotic Treatment in Community
Behavioral Health Organizations, Outcomes (REACH OUT)
study was a naturalistic, observational study of adult patients
receiving usual course of treatment for schizophrenia or
bipolar I disorder in CBHO. Patients were followed for 1 year
with assessments at enrollment, 6 months, and 12 months
collected via participant interviews, medical chart abstracttion, and clinical surveys. This analysis compared the
characteristics and demographics of patients with Schizophrenia treated with paliperidone palmitate, risperidone
long-acting injectable, or OAT. Differences between LAI and
OAT were assessed by t-tests for continuous variables or chisquare tests for categorical variables, with no multiplicity
adjustment. Results: A total of 1065 patients were enrolled
from 46 CBHO. A total of 880 patients with schizophrenia
were analyzed. The majority of patients in the Schizophrenia
cohort were treated with an atypical LAI [paliperidone
palmitate (n=482; 54.8%) or risperidone LAI (n=117; 13.3%)],
while 281 (31.9%) received oral antipsychotics. Patients had a
mean age of 41.4 years, and most were male (70.3%) and of
white (50.1%) and/or black (32.8%) race. Age, gender,
education level, and living situation were similar between
the LAI and OAT cohorts. Similar rates of hypertension,
hyperlipidemia, and heart disease were observed within the
cohorts, but significantly higher percentages of LAI patients
were daily smokers (62.1% vs. 52.6%, p=0.026) or consumed
more alcohol than recommended (24.4% vs. 17.1%, p=0.017)
compared to OAT patients, respectively. Significantly higher
percentages of LAI patients were Medicare (52.2% vs. 37.6%,
p<0.001) or Medicaid (75.6% vs. 62.6%, p<0.001) recipients in
comparison to OAT patients, respectively. The mean age of
first hospitalization for schizophrenia-related symptoms was
significantly lower for LAI patients than OAT patients (24.2
years vs. 26.2 years, p=0.02). Conclusions: This study demonstrated some differences in characteristics of patients with
schizophrenia who were treated with atypical LAI and OAT
in CBHO. Further comparative analyses using propensity
score matching are planned to investigate possible differences in the healthcare resource utilization, treatment
patterns, and patient reported outcomes between the LAI
and OAT cohorts.
of harm to suicide and homicide, however many outcomes
are less unequivocal in nature. Potential causes of these
outcomes are identified incorporating variables potentially
confounding causal relations between treatments and adverse outcomes. Discussion/Conclusions: Systematic knowledge on the potentially harmful effects or adverse outcomes
of many psychosocial interventions in psychiatry and mental
health services—where possible chances of such outcomes
are present—is largely absent. Systematic attention for
possible adverse outcomes in research designs measuring
the effectiveness of such interventions also seems absent. A
wealth of potentially intrusive interventions is thus carried
out daily without knowledge of its effects. Methodological
options, including designs and instruments, that take
adverse outcomes into account more systematically are
discussed.
P1-30
PREVALENCE OF ABUSE IN CHILDREN WITH
DISABILITIES: A CASE REPORT
Lead Author: Mehr Iqbal, M.D.
Co-Author(s): Suzi Duwaik, M.S.
SUMMARY: AH is a 7 year old Caucasian female with a past
medical history of cystic fibrosis who came to the children's
psychiatric unit at Bergen Regional Medical Center presenting with behavioral disorder, homicidal ideation, hypersexual behavior, and psychotic traits in February 2014. When
she was 5, she was allegedly sexually abused by her
godfather, who admitted to the abuse but fled to another
state before being prosecuted. It is possible that her presenting symptoms were precipitated by the sexual abuse. We
believe that early intervention after the abuse occurred
would have greatly reduced the severity of her psychiatric
symptoms, and that clinicians need to promptly and aggressively treat abused disabled children abuse seems to be
prevalent among disabled children. A meta-analysis of 17
studies published in 2012 found that 13.7% of disabled
children were sexually abused with an odds ratio of 2.88. This
same study also noted that the scarcity in studies, the lack of
reporting of abuse, and the insufficient assessment of the
abuse makes gathering relevant statistics difficult. As
reported by the Vera Institute of Justice, disabled children
are at the mercy of their caregivers, who are the main culprits
in the sexual abuse. The caregivers participate in the daily
personal activities of the disabled child, they can prevent
that child from any knowledge pertaining to protecting
themselves or reporting the abuse, and if the child is
institutionalized the caregivers are rarely caught or punished
for their crimes. Thus, the lack of oversight of the caregivers
lends itself to the opportunities necessary to sexually abuse
the disabled child. Once the disabled child is finally treated
for the abuse, they tend to have more negative outcomes
such as sexual abuse leads to longer hospital stays, more
medication use during the stay and at discharge, and greater
incidence of psychotropic medication use. This research
suggests that sexually abused children have increased
psychiatric morbidity, and they need "trauma-informed
treatment" targeting this abuse in relation to their
psychiatric conditions.
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AMERICAN PSYCHIATRIC ASSOCIATION
P1-33
FACEBOOK AND SUICIDE - CASE REPORT AND REVIEW
OF LITERATURE
Lead Author: Tanuja Gandhi, M.D.
Co-Author(s): Ushama Patel, M.D.
SUMMARY: Introduction: Suicide, a preventable public
health problem was the 10th leading cause of death in 2010
averaging to 105 suicides per day. Social media, particularly,
Facebook is noted to be used as a portal for the expression of
suicidal thoughts, suicide announcements and rarely,
suicide videos as reported here. This is a concerning,
emerging trend under-reported in formal literature. We
hereby present a unique case of a suicide attempt video
being posted on face book and discuss the reviewed
literature. Case Presentation: Ms. Y, a 16y/o girl with prior
diagnosis of ADHD and Depression presented for evaluation
with her mother as her mother had recently learnt that Ms. Y
had posted a suicide video of herself on Facebook. During
evaluation, Ms. Y reported that on the video she said, "My
death will be more beautiful than my smile" then took some
pills and posted the video on face book. She clarified though,
that she took few pills due to a change of mind but posted
the video. After initial evaluation, Ms. Y was hospitalized for
acute inpatient stabilization and treatment. Methods: We
reviewed literature using keywords 'social media' and
'suicide' on PubMed and Google scholar. We also reviewed
using keywords 'Facebook' and 'suicide' that yielded just 3
articles on PubMed. Discussion: With the increasing popularity of social media, it is possible that users may feel
comfortable in disclosing their feelings in the safety of a
virtual environment thus impacting adolescent behaviors,
particularly suicidal behaviors. Popular media has numerous
reports on Facebook posts of suicide but limited literature on
Face book videos of a suicide attempt (3). While face book
can be utilized as a tool to identify high-risk candidates and
avert potential suicide attempts due to its widespread
accessibility, it may also cause the Werther effect (1) thus
potentiating copycat suicides. Conclusion: It's essential for
clinicians to be aware of this emerging trend and screen for
social media use, particularly Facebook in adolescents. This
may prove invaluable in instituting a safety plan for at risk
individuals and avert a crisis situation. Furthermore, though
there are protocols developed for identifying suicidal
comments and crisis intervention on Facebook, there is
limited awareness of these in medical professionals. We thus
reiterate the importance of clinical practices to be at par with
the current socio-cultural trends.
Bibliography:
P1-32
A PHYSCIAN-HEALTH PLAN COLLOBORATIVE SOLUTION
FOR ACHIEVING PRIMARY CARE MENTAL HEALTH
INTEGRATION
Lead Author: Judith Feld, M.D.
Co-Author(s): Aubrey Balcom, M.B.A., Jay Swarthout,
L.M.H.C.
SUMMARY: BACKGROUND: Integrating behavioral health
competencies within the primary care setting has become a
widely accepted healthcare delivery imperative in order to
improve healthcare quality, patient experience of care and
affordability. Approximately half of all patients in primary
care present with psychiatric co-morbidities, and 60% of
psychiatric illnesses are treated in primary care. There are
numerous national models of collaborative care, notably the
IMPACT model for managing depression in older adults as
well as the DIAMOND initiative in Minnesota, a multistakeholder collaborative program supporting the treatment
of depression in primary care. Despite these successful
initiatives demonstrating improved clinical outcomes and
patient experience, and lower total costs for healthcare,
significant barriers to implementing these models remain.
These barriers include reimbursement constraints in fee-forservice, stigma, fragmentation and medical training and
culture. MODEL: Independent Health, a community-based
not-for-profit health plan in Western New York, has partnered with 29 community-based primary care practices to
transform healthcare delivery through resource support,
medical management innovation and a shared savings
reimbursement model. As part of this collaboration, ten of
these primary care practices will participate in a two-year
program, beginning June 2014, in which they will hire
licensed mental health counselors as primary behavioral
health care consultants to work as full-time employees in the
primary care team. This program will be funded through a
collaboration of Independent Health, two prominent
community foundations, as well as the primary care practices. Components of the program include training mental
health providers to work in a primary care setting, as well as
training the primary care team in collaborating with their
new team members. Psychiatric consultation will be available to support the practices. Half of the practices are
pediatric and the other half consists of adult practices
serving urban, suburban and rural populations.
DISCUSSION: This model is unique in that is supported by
global value-based reimbursement instead of a case rate for
a specific condition. The program supports all primary care
populations and is payer-agnostic. Additional strengths
include a strong community focus, customized practice
interventions, and a sustainable business model. Program
metrics will include improvement in markers of targeted
chronic health conditions, improvement in functional
capacity for patients with mental health and substance use
disorders, as well as the cost impact of the intervention
through analyzing data on level of care utilization and total
cost of care. We hope this model can serve as a template for
community-based behavioral health integration implementtation in non-integrated health care delivery systems. We
plan to publish our results and present our findings at future
APA meetings.
1. Ruder, T. D., Hatch, G. M., Ampanozi, G., Thali, M. J., & Fischer, N.
(2011). Suicide announcement on Facebook. Crisis: The Journal of Crisis
Intervention and Suicide Prevention, 32(5), 280-282.
2. Jashinsky, J., Burton, S. H., Hanson, C. L., West, J., Giraud-Carrier, C.,
Barnes, M. D., & Argyle, T. (2013). Tracking Suicide Risk Factors Through
Twitter in the US
3. Ahuja, A. K., Biesaga, K., Sudak, D. M., Draper, J., & Womble, A. (2014).
Suicide on facebook. Journal of Psychiatric Practice®, 20(2), 141-146.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
P1-35
"NEGATIVE" SCHIZOPHRENIA: EMOTIONAL AND
FUNCTIONAL OUTCOMES
Lead Author: Nataliia Orlova, M.D., Ph.D.
Co-Author(s): M. Skliar, M.D.
SUMMARY: Objective: Schizophrenia is among the top 10
disabling conditions worldwide for young adults. Patients
with schizophrenia struggle with much functional impairment, including performance of independent living skills,
social functioning, and occupational/educational performance. Aims: studying emotional and functional outcomes at
patients with schizophrenia. Materials and methods: PANSS
—for assessment negative symptoms, SHPS—for assessment
hedonic tone. For assessment social functioning and quality
of life used GAF, SDS, GWB. Results: Were studied 115 inpatients with schizophrenia (295.30) with dominant negative
symptoms. The main characteristics for those patients were:
male (r=0,277; p≤0,05), age 21-30 (r=0,690; p≤0,05) and 31-40
(r=0,378; p≤0,05) years old, high school education (r=0,906;
p≤0,01), single (r=0,637; p≤0,01), who live with parents
(r=0,963; p≤0,01), unemployed patients (r=0,926; p≤0,05)
with disability degree (r=0,797; p≤0,01). In clinical and
psychopathological status, patients have full-blown negative
symptoms on PANSS negative. They had "social" anhedonia
(52,2%), blunted affect (r=0,277; p≤0,05), emotional
withdrawal (r=0,322; p≤0,05), poor rapport (r=0,284; p≤0,05),
lack of spontaneity and flow of conversation (r=0,279;
p≤0,05). Were some depressive symptoms like reduced sleep
(r=0,431; p≤0,05), reduced appetite (r=0,437; p≤0,01). GWB (0,282; p≤0,05), GAF (0,172), SDS (0,343; p≤0,05). Summary:
were indicated that at patients with "negative" schizophrenia
had lower indexes in all study criteria. It gives a poor
prognosis in emotional and functional outcomes and
increase in disability.
P1-34
MATERNAL PSYCHOSIS AND THE LAW: HELPING
PSYCHIATRISTS NAVIGATE THE BALANCING ACT OF
CARING FOR MOTHER AND FETUS IN THE SERIOUSLY
MENTALLY ILL
Lead Author: Sarah Noble, D.O.
Co-Author(s): Samidha Tripathi, M.D., Tanuja Gandhi, M.D.
SUMMARY: Objectives: 1. To understand the ethical and
legal dilemmas involving a pregnant patient with psychosis
(intra/puerperal/post-partum) 2. Identify possible measure
to provide women with mental health issues, with more
autonomy. 3. Identify the need for an inter-department and
agency based collaborative approach to formulate least
restrictive measures for pregnant women with psychosis.
Method: PubMed and Google Scholar databases were
searched using the following key words: Pregnancy,
Psychosis, Ethics, Mental health laws. Background: A
psychiatric diagnosis, particularly psychosis, does not imply
that the patient lacks capacity. But, mental illness can reduce
a patient's ability to regulate emotions and adapt to change.
This is of particular concern during the dynamic period of
pregnancy. Women are often tempted to stop their
medication as well, so it can create a perfect storm for
relapse of symptoms. Maternal schizophrenia is an independent risk factor for low APGAR scores, intrauterine growth
retardation, and congenital defects as well as losing custody
of children. Discussion: Over the years, different approaches
have been applied towards the management of psychoses in
pregnancy including but not limited to involuntary hospitalization, forced treatment and even incarceration of the
mother when drugs have been involved. Psychiatric
Advanced Directives (PAD) have been widely discussed and
variably accepted in multiple states in the US but there is no
uniform consensus with respect to psychotic episodes in
pregnancy. Literature suggests that the completion of PAD's
while competent prior to or during early pregnancy would
help in the allocation and mobilization of resources
appropriately. This will help to maintain her wishes and
balance the health of the fetus with them. Thus, we suggest
that PAD's be applicable for pregnancy as well and propose
simple guidelines outlining the process that would help
identify women who would otherwise present to the
clinician during an acute psychotic episode. This involves
identifying a proxy, either case manager or family member
who will help the patient maintain prenatal care and
psychiatric follow up, during the course of pregnancy,
thereby minimizing the need for involuntary hospitalization.
Conclusion: Pregnancy and psychosis, pose a challenge, not
only for the treatment team but also for the psychiatrist.
Capacity evaluations for refusal of treatment, court ordered
treatment and can limit patient involvement. Factors like
fear of medico-legal consequences, physician's anxiety, lack
of understanding of the rights of patients to refuse treatment,
and a misunderstanding of the physician's duty when
presented with such scenarios, and limited communication
between the patient and treatment team, need to be
explored prior to patient break-down so that the will of the
patient, the safety of the fetus, and the clinical expertise of
the doctors are all in-line.
P1-36
HYPONATREMIA INDUCED PSYCHOSIS: A CASE REPORT
Lead Author: Zahid Islam, M.D.
Co-Author(s): Mary J Bapana M.D.; Asghar Hossain, M.D.
SUMMARY: Introduction: Hyponatremia is a common electrolyte imbalance in clinical practice. Clinical manifestation
often goes undetected and undiagnosed. However severe
hyponatremia can cause neurological and neuropsychiatric
complications and can ultimately be fatal if left untreated.
There are various causes of hyponatremia including polydipsia. Hyponatremia does occur in psychiatric patient
which may or may not be aggravated by primary polydipsia.
hyponatremia induced psychosis is uncommon. Objective:
The objective of this article is to report a case of hyponatremia induced psychosis caused by non-psychogenic
polydipsia, and to review the available literature from Pub
Med, Google and UpToDate. Case: SJ is a 60 year old
Caucasian female homemaker living with her husband.
Patient was brought to the emergency department due to
altered mental status. Reportedly the patient had an argument with a family member, got naked and ran out on to the
street. The patient was brought to the ER by EMSl for further
evaluation. On initial evaluation patient was agitated, did not
recognized her husband, verbally abusive to the staff and has
disorganized thoughts. On Physical examination vitals are
stable. Extremities showed mild edema. All other review of
systems was normal. Patient had to medicate with IM
medication for the psychosis. Laboratory result showed
hemoglobin of 10.4, platelets of 480,000, Serum sodium of
124 mEq/ l, serum osmolality of 262 and urine osmolality of
63
AMERICAN PSYCHIATRIC ASSOCIATION
offered. New delivery models which transcend traditional
"brick and mortar" services (Kazdin & Blask, 2011) are listed.
The poster also includes ways technology may be applied to
clinical procedures and psychoeducation. Finally, the poster
puts forward ideas for collaboration between CBT oriented
clinicians and pediatricians.
398. All other labs were within normal limits. Patient was
admitted in the medical floor with diagnosis of Psychosis due
to hyponatremia. She was started on normal saline with
restriction of fluid to correct her hyponatremia. On day one,
two patients continued to exhibit psychotic behavior. In the
meantime her sodium level is going to the normal limit. On
day three patient came to her baseline functioning and did
not exhibit any psychotic symptoms. Patient reported that
she drunk more than ten diet soda per day for past one week.
Diagnosis was made as Psychosis due to hyponatremia
precipitated by non-psychogenic polydipsia. Discussion:
Review of available literature has shown hyponatremia due
to compulsive water drinking, the syndrome of inappropriate
antidiuretic hormone secretion (SIADH), and the syndrome
of self-induced water intoxication (SIWI) is common in
previously diagnosed psychiatric patient where hyponatremia induced psychosis is rare. More recently a case was
reported, a factory worker in India who developed Psychotic
symptoms after developing hypontremia due to dehydration
with salt depletion because of high temperatures. In
conclusion we found that non-psychogenic polydipsia is a
rare cause of hyponatremia. Therefore a high index of
suspicion must be maintained in psychotic patients with a
first episode of psychosis with no previous psychiatric
history. The early detection and treatment of Hyponatremia
can decrease morbidity and mortality.
P1-38
THE USE OF PHARMACOLOGICAL AGENTS TO IMPROVE
SLEEP IN CHILDREN AND ADOLESCENTS WITH AUTISM
SPECTRUM DISORDERS: A SYSTEMATIC REVIEW AND
META-ANALYSIS
Lead Author: Kathleen M. Patchan, M.D.
Co-Author(s): Alainia Morgan-James, M.D.
SUMMARY: Content: Sleep disturbance is a frequent complaint among children and adolescents with autism
spectrum disorders (ASD), affecting the quality of life of
children and caregivers. Objective: This meta-analysis
assesses the efficacy of pharmacological agents to improve
overall sleep in subjects with ASD. Data sources: Electronic
databases (PubMed, PsycInfo) were searched on October 3,
2013 for randomized clinical studies involving children with
ASD who were given pharmacological agents for sleep
disturbance. Articles were restricted to the English language.
There was no publication time restriction. Study selection: A
total of 36 articles were initially identified. Six duplicates
were removed and 13 were excluded as they did not meet
inclusion criteria. Another eight studies were removed
because they were open trials, not randomized, or used
broad definitions. Three studies were excluded because their
data were not comparable. Six articles were included in the
meta-analysis. The Cohen statistic was 0.748, indicating a
high level of inter-rater reliability for study inclusion. Data
extraction: Outcome data-sleep latency, total sleep time, and
sleep awakenings-were extracted using mean and standard
deviation. Study quality was assessed using the Cochrane
approach with most studies having low to moderate risk.
Results: Meta-analysis evaluated the efficacy of pharmacological agents on sleep behaviors of children with ASD.
The analysis of all pharmacological agents (i.e., melatonin
and secretin) showed that there was a moderate, statistically
significant improvement in total sleep time [SMD -0.65 (95%
CI: -1.14, -0.15)], large, statistically significant improvement
in sleep latency [SMD 0.91 (95% CI: 0.60, 1.22)], and minimal,
non-statistically significant improvement in sleep awakenings [SMD -0.23 (95% CI: -0.81, 0.34)]. When studies
examining melatonin were analyzed separately, total sleep
time [SMD -0.61 (95% CI: -1.08, -0.13)] and sleep latency
[SMD 0.99 (95% CI: 0.69, 1.29)] improved and remained
statistically significant with a greater effect noted in sleep
latency compared to the use of all pharmacological agents.
Sleep awakening, though improved, was not statistically
significant [SMD 0.10 (95% CI: -0.24, 0.44)]. No publication
bias was found. Article heterogeneity was insignificant.
Conclusion: Melatonin increased total sleep time and
decreased sleep latency with cognitive behavioral therapy
improving both. There were negligible outcomes on sleep
awakenings. Secretin had negligible or worse outcomes for
total sleep time and sleep awakenings. The use of secretin on
sleep latency was conflicting with one arm showing
improvement and another showing worse outcome.
P1-37
WORKING WITH CHILDREN IN THE NEW ERA OF HEALTH
CARE REFORM: WHY BEING A CBT ORIENTED CLINICIAN
HELPS
Lead Author: Robert Friedberg, Ph.D.
Co-Author(s): Jenna Paternostro; Szimonetta Mulati; Laura
Brehm
SUMMARY: Health care reform is the new reality. More
specifically, the Patient Protection and Affordable Care Act
(ACA) include imperatives for evidence-based treatment,
quality indicators, early intervention/prevention, technological innovations, new delivery models, and collaborative
care. These initiatives are especially welcome developments
in children's mental health care where studies investigating
the effectiveness of psychotherapeutic practices in usual
care settings are dismally disappointing (Garland et al., 2013;
Weisz, 2004). The current zeitgeist in pediatric behavioral
healthcare is prompting both public and private sector
providers to bring their practices into alignment with the
ACA demands as well as build pioneering programs.
Fortunately, cognitive behavioral (CBT) spectrum models are
well-equipped to meet these emerging mandates (Friedberg
et al., 2014a, 2014b). Accordingly, this poster explains how
CBT is well-suited to the contemporary health care arena
and offers several state-of-the-art recommendations for care.
Modular CBT represents a first-line empirically supported
approach to most childhood disorders (Chorpita et al., 2011;
Friedberg et al., 2011; Hoagwood et al., 2014; Kataoka et al.,
2014; Southam-Gerow et al., 2014: Starin et al., 2014). Ongoing treatment monitoring and establishing quality
indicators are basic ingredients in CBT spectrum
approaches. This poster provides attendees with suggestions
for clinically relevant outcome metrics. Additionally, suggestions for early intervention and prevention programs are
64
2014 INSTITUTE ON PSYCHIATRIC SERVICES
tioning, and the Clinical Global Impression-Severity scale.
FINDINGS: Of the 642 patients who were admitted, 92 did
not complete treatment (died, were transferred or left
against advice) or received a diagnosis other than
schizophrenia (SZ), SZA or mood disorder (MD). Consensus
diagnosis differed from referral diagnosis in 27% of cases. Of
378 patients referred with SZ, the consensus diagnosis was
SZ in 78%, SZA in 15%, MD in 2%, and other in 5%. Of the 145
referred with SZA, the consensus diagnosis was SZA in 63%,
SZ in 26%, MD in 3%, and other in 2%. Two thirds of the SZA
group were bipolar type. People with confirmed MD or SZA
tended to be older and had a longer illness duration, and
were more likely to be female, noncaucasian, and married.
Functioning and symptom severity in the preceding year and
at admission were worse in SZ than SZA patients. PANSS
positive scores were greater for SZ and SZA than MD, and
PANSS negative scores were more severe in SZ than SZA or
MD. Prior depressive episodes were very common in MD
(98%) and SZA (89%), but 35% of SZ patients also had a
previous depressive episode. Lifetime substance use disorder
was found in 63% and recent substance abuse in 35% of
patients, and these proportions did not differ across
diagnoses. At admission, SZA patients were more likely than
SZ patients to have been on a mood stabilizer, but the mean
number of antipsychotics and total amount (defined daily
dose) did not differ. CONCLUSION: In a series of patients
with treatment-resistant psychosis, the most common
diagnosis was SZ, but 29% had SZA. SZA patients were
frequently misdiagnosed in the community, and compared
to SZ patients, tended to have better baseline functioning,
lower symptom severity, were older, and had been ill longer.
P1-39
DISCHARGING PATIENTS ADMITTED FOR ACUTE
PSYCHIATRIC STABILIZATION IN GUELPH - CARING FOR
THEIR NEEDS IN THE COMMUNITY - A QUALITY
ASSURANCE PROJECT
Lead Author: Natasha Snelgrove, M.D.
Co-Author(s): Andrew Costa, Ph.D., Alan Eppel, M.B.,
F.R.C.P.C.
SUMMARY: Care transitions are a critical part of mental
health care for patients discharged from inpatient settings.
In Guelph, Ontario, Canada, the local psychiatric crisis and
stabilization unit relies primarily on a community addiction
services agency and the Canadian Mental Health Association
(formerly Trellis) for outpatient resources for discharged
patients. A retrospective chart review of 25 charts during the
July to December 2012 time period was undertaken to look at
how referral processes could be better tailored to provide
more seamless follow-up care for discharged inpatients. We
explored demographic and clinical variables, including
diagnosis, to length of stay (LOS) and links to follow-up care
within the community. Although diagnoses of SPMI (Severe
and Persistent Mental Illness) and primary Axis II diagnoses
positively predicted LOS (16.6 +/- 5.2 and 22.0 +/- 7.1 days
respectively), and Substance Use Disorder (SUD) negatively
predicted LOS (10.6 +/- 5.9 days), no demographic or clinical
factors correlated with later ongoing follow-up with mental
health or psychiatric supports in the community. Furthermore, many patients with SUD were not referred for
addiction services treatment (43% of patients lacked
referral). In addition, the SPMI population showed some
preliminary evidence of both increased complexity and
severity of illness as well as underserviced needs, as
demonstrated by multiple factors, including increased likelyhood of HCV positive status (37.5% of sample vs 0% of nonSPMI) and lack of primary care physician (37.5%). Many
areas for potential intervention to improve discharge and
better use our limited psychiatric and mental health
resources may be possible as a result of this preliminary
data.
P1-41
A SHOCK IN TIME: DEJA VU FOLLOWING
ELECTROCONVULSIVE THERAPY
Lead Author: Ashley J.B. MacLean, B.Sc., M.D.
Co-Author(s): Dr. Adekola Alao
SUMMARY: Background Well-known side effects of electroconvulsive therapy (ECT) include amnesia, cognitive
dysfunction and cardiovascular and respiratory complications (1). However, déjà vu following ECT and the underlying
mechanism has not been well studied. Methods: A case of
persistent déjà vu following ECT treatment for depression is
discussed. The literature on the side effects of ECT, identified
by a PUBMED search, using the key words, electroconvulsive
therapy, side effects, déjà vu is reviewed. Results: Patient is a
31-year-old male, previously diagnosed with major depresssion, who underwent 11 ECT sessions after failing to respond
to different pharmacological agents. Patient subsequently
developed déjà vu; feeling that many of the experiences he
was going through had occurred in the past. Discussion:
There have been no prior case reports in the literature of déjà
vu following ECT. However, an Internet search using the
words ECT and déjà vu brings up several discussion boards
where patients have expressed experiencing déjà vu following ECT. This would suggest that the phenomenon is not as
rare as its scarce reporting in medical literature would lead
one to believe. The mechanism of action of ECT is unclear.
However, in bitemporal lobe ECT, electric current is passed
across the temporal lobes. It is well known that déjà vu is
seen in temporal lobe seizures as well as a phenomenon that
occurs in the general population (2). Thus, it can be
postulated that déjà vu following ECT is related to seizure
activity induced in the temporal lobes. In an article by Spatt J
(2002), he argues that déjà vu is the "result of a false
P1-40
TREATMENT-RESISTANT PSYCHOSIS: DIAGNOSTIC AND
CLINICAL CHARACTERISTICS OF A LARGE CASE SERIES
Lead Author: Randall F White, M.D.
Co-Author(s): Geoffrey N. Smith, PhD, Sean W. Flynn, MD,
Ivan Torres, PhD, William G. Honer, MD
SUMMARY: OBJECTIVES: Patients in British Columbia who
have treatment-resistant psychosis may receive care in a
publicly funded academic program where each patient
undergoes a multidisciplinary diagnostic evaluation. We
describe this assessment process and present findings on a
series of patients including a large number with treatmentresistant schizoaffective (SZA) disorder. METHOD: All
patients admitted to the refractory psychosis ward at
Riverview Hospital between 1993 and 2010 had failed to
respond to at least two previous antipsychotic trials. A
psychiatrist, social worker, pharmacist, nurse, general
physician, and neuropsychologist evaluated each patient. All
available summaries of previous psychiatric admissions were
reviewed, and medical, pharmacological, social and behaveioural histories were recorded. All information was presented
at a case conference and a DSM-IV multiaxial diagnosis
reflected agreement between at least two psychiatrists and a
psychologist. Symptom ratings included the Positive and
Negative Syndrome Scale, the Global Assessment of Func65
AMERICAN PSYCHIATRIC ASSOCIATION
interesting that although most inmates often have access to
objects such as razor blades, which can be used for selfinjury, they generally prefer to ingest them. [1]. Some of
those patients prefer to wrap sharp objects in paper prior to
ingestion [2] suggesting that suicide is not the motive.
Conclusion: This case illustrates that the motivation for
ingestion of foreign bodies is diverse and not always an act of
suicide. Further studies focusing on the specific type of
trauma that may be etiological in self-injurious behavior are
warranted.
References
activation of connections between mesiotemporal memory
structures and neocortical areas directly involved in the
perception of the environment." According to this theory,
"déjà vu experiences reflect an inflexible parahippocampal
recognition memory system, responsible for feelings of
familiarity, working in isolation while the more flexible
hippocampal recall system is not involved." Further
electrophysiological studies involving epileptic patients will
help elucidate the specific brain regions involved (3).
Conclusion: This case report serves to illustrate déjà vu as a
side effect of ECT. The underlying mechanism for ECT
induced déjà vu is unclear thus, further studies are
warranted with the hope that a greater understanding into
the etiology of ECT induced déjà vu will provide us with
answers on how to prevent it or minimize ECT induced
memory impairment in general.
References
1. Karp JG, Whitman L, Convit A. Intentional ingestion of foreign objects
by male prison inmates. Hosp Community Psychiatry. 1991; 42: 533-5.
2. Johnson WE. On ingestion of razor blades. JAMA. 1969; 208: 2163.
P1-43
ATTITUDES TOWARDS LONG-ACTING INJECTABLE
ANTIPSYCHOTICS (LAI) IN FIRST EPISODE PSYCHOSIS
(FEP)
Lead Author: Nishardi Tharu Wijeratne, M.D., M.H.Sc.
Co-Author(s): Ranjith Chandrasena MD, FRCPC
SUMMARY: Introduction: Research indicates that psychiatrists offer Long-acting injectibles (LAI) to only 35% of
eligible patients and treat less than 20% of eligible patients
with LAI. This poster will discuss current evidence on
attitudes towards LAI in FEP (First Episode Psychosis) and
explore attitudes towards LAI in patients attending an Early
Psycho-sis clinic Methodology: Applying qualitative methodology, 13 FEP patients who had never been on LAI were
interviewed using semi-structured interviews. Informed
consent was obtained from individual participants and local
REB approval obtained for the project. Enablers and barriers
for using a LAI were explored. Using grounded theory, data
was analyzed and reduced to key themes which are
described. Results: Enablers for using LAI in FEP include
safety; convenience; reduction of stigma and trust in the
treatment team. Barriers include side effects; lack of personal
control; flavour of suspicion towards injections and alluding
to drugs of abuse. Discussion: Strengths of the study include
its qualitative nature which allows exploration of patient
experience and attitudes. Since the patient group is a LAI
naïve young adult group, a unique perspective is obtained.
Limitations of the study include low generalizability due to
the very specific patient population. Patients' level of
functioning and current symptamatology was not assessed
which may also limit the usefulness of data. Conclusion:
There is a relationship between attitudes, prescribing habits
and patient acceptance of LAI in FEP. Previously unexplored
patient factors affecting uptake of LAI include medication
safety, concept of stigma, suspiciousness towards LAI and
relationship with drugs of abuse. Stakeholder attitudes
provide a window of opportunity to unravel underutilization
of LAI in FEP.
1. Alao AO: ECT in the medically ill elderly: a case report. Int J Psychiatry
Med. 2002;32(2):209-13.
2. Illman N. A., Butler C. R., Souchay C., Moulin C. J. Deja experiences in
temporal lobe epilepsy. Epilepsy Res. Treat. 2012;
15.10.1155/2012/539567.
3. Josef Spatt. Déjà Vu: Possible Parahippocampal Mechanisms. The
Journal of Neuropsychiatry and Clinical Neurosciences. 2002;
Feb;14(1):6-10.
P1-42
CURIOUS APPETITES: INMATES AND THE FOREIGN
BODY
Lead Author: Ashley J.B. MacLean, B.Sc., M.D.
Co-Author(s): Adekola Alao, M.D., Mirabelle Mattar
SUMMARY: Background: Ingestion of foreign objects is well
recognized in pediatrics, surgery and emergency medicine.
Less reported in the literature is intentional ingestion of
foreign objects within the context of a psychiatric illness. In
the inmate population, this behavior is becoming a trend
and is associated with a psychiatric illness [1]. Methods: A
case of deliberate ingestion of a screw by an inmate in the
absence of suicidal intent is discussed. The literature on
inmate foreign body ingestion, identified by a PUBMED
search, using the key words, inmate, foreign, body, ingestion,
psychiatry, is reviewed. Results: The patient K.C is a 43-yearold male prisoner who presented to the Emergency department following ingestion of a screw. Patient had a selfreported psychiatric history of major depression, anxiety,
borderline personality disorder and PTSD. Patient described
worsening anxiety due to lack of emotional support resulting
from his incarceration. Prior to presentation, patient initially
planned to cut his forearm with the screw but impulsively
swallowed it to seek attention with the hopes it would cause
internal damage but not expecting death as an outcome.
Discussion: Prisoners ingest foreign body objects for a
variety of reasons including attempted suicide, the need for
secondary gain (such as hospital vacation) or as a result of
command auditory hallucinations within the context of a
chronic psychiatric illness such as schizophrenia. It may also
be secondary to attention-seeking behavior as occurs in
borderline personality disorder [1]. In their 1895 Studies on
Hysteria, Sigmund Freud and Joseph Breuer declared that
"psychical trauma—or more precisely the memory of the
trauma - acts like a foreign body which long after its entry
must continue to be regarded as an agent that is still at work"
The patient denied a history of suicide attempts prior to
incarceration. We speculated that the trauma of being in
prison as well as learned behavior from other prisoners
might predispose these patients to act this way. It is
P1-44
PSYCHOPATHOLOGY, TEMPERAMENT AND ATTACHMENT STYLES OF PARENTS WHOSE CHILDREN AND
ADOLESCENTS HAVE BEEN SEXUALLY ABUSED
Lead Author: Aynil Yenel
Co-Author(s): Sermin Kesebir, M.D.
SUMMARY: The parents of the children and adolescents,
who have been sexually abused, are the subject of many
studies. There are few studies that analyze the first axis the
second axis, the temperament and the attachment styles
diagnose systematically. It was analyzed that 80 mothers
and 66 fathers were the parents of children who have been
66
2014 INSTITUTE ON PSYCHIATRIC SERVICES
LIP. Results: 1314 child psychiatrists completed the survey
in full, yielding a 31.7% response rate. Almost all respondents
surveyed were aware of recommendations for monitoring
(97%), but fewer agreed with them (GLUC: 80.4%; LIP:
68.6%). In the course of a year, less than half reported they
completed lab monitoring on three or more occasions
(GLUC:46.3%; LIP: 44.3 %) Multiple regression results show
that physician awareness of the recommendations (GLUC: B
= 1.303, p < .001; LIP: B= 1.183, p < .001), ease of keeping up
with the guidelines (GLUC: B = 0.260, p = .002; LIP: B= 0.277,
p = .001), working within an academic practice (GLUC: B =
0.310, p = .001; LIP: B = 0.256, p =.003) and perceived
importance of the guidelines in patient care (GLUC: B =
0.438, p < .001; LIP: B= 0.468, p < .001) all predicted compliance with guidelines. Physician time in practice was
inversely proportional to compliance (GLUC: B = - 0.106, p =
.005; LIP: B= -0.123, p < .001). Conclusions: Most child
psychiatrists reported awareness of, and agreement with,
guidelines for SGA metabolic monitoring, however, less than
half reported they routinely monitored children on these
medications. Our findings suggest that interventions to
improve monitoring should target attitudes about monitoring, physicians in non-academic practices and physicians
who have been out of training for long periods of time.
sexually abused. Diagnostic interviews were done with SCIDI and II, temperament and attachment forms were rated with
Temps-A Temp. Parents of children without sexual abuse
history were included to this study as a control group. Scale
and with Adult Attachment Forms Scale. In this study, 11.4%
of cases, the perpetrators are the fathers themselves (n=12).
In these, parents’ attachment forms do not differ from the
control group but the temperament forms are found to be
more in depressive-anxious and cyclothymic in mothers (p <
0.05). The percentage is 81.3% in mothers and 47% in fathers
who have sexually abused children as first axis clinical
disorders. These percentages were found to be 100% for
second axis personality disorders in both mothers and
fathers. The most seen diagnoses are anxiety disorders (in
mothers 40%, in fathers 21.2%) and affective disorders (in
mothers 32.5%, in fathers 9.1%). The most seen personality
disorders are addiction (20%) in mothers and obsessivecompulsive (10.6%) and passive aggressiveness in fathers
(28.8%) and avoidant personality disorders in both (in
mothers 20%, in fathers 13.6%). Self-defeating personality
disorders for mothers, 8.8% which are set C personality
disorders. This study shows the lack of protective properties
of mothers of the children and adolescents that have sexual
abuse. This study also showed that it is harder to get in
contact with fathers and that they are recessive to talk about
sexual abuses as another remarkable fact which makes the
study limited.
P1-46
COGNITIVE FUNCTIONS, APOE GENOTYPE, AND
HORMONAL REPLACEMENT THERAPY IN A
POSTMENOPAUSAL POPULATION
Lead Author: Kasia Gustaw Rothenberg, M.D., Ph.D.
Co-Author(s): Angela Wójcik-Fatla, Ph.D., Edyta DługoszMazur, M.S., Iwona Bojar, M.D. Ph.D.
SUMMARY: Introduction: Growing body of evidence
suggests that estrogen plus progestogen therapy (EPT) may
modify the risk of developing dementia in the ApoE polymorphism related manner. The mechanism and subsequently clinical importance of such an effect remains however
unexplained. Aim: The objective of this study was to explore
the influence of EPT on cognitive functioning of women in
their postmenopausal stage of life in relation to APOE polymorphism. Methods: The group of 107 women was selected
(53 women on EPT) for the final evaluation. Two years from
the last menstruation as well as FSH level >30 U/ml and the
lack of cognitive impairment on MoCA were considered the
inclusion criteria. Computerized battery of test CNS-Vital
was used to assess cognitive functions. ApoE genotype was
determined by multiplex PCR. Statistical analysis was
performed using STATISTICA software. Results: Majority of
women scored below 50 percentile on all the cognitive
domains tested, especially on speed of processing. The
presence of ApoE4 corresponded with the decreased
functioning as opposed to ApoE2 which was present in
women with better level of functioning overall and specifically in: processing speed, executive functioning, psychomotor speed, Reaction time, Complex attention and Cognitive flexibility. EPT seemed to improve functioning only in
processing speed. E2/ε3 and ε4 carriers supplemented with
EPT functioned significantly better in speed processing when
compared to those none treated. The opposite effect
however was observed in ε3/ε3 carriers. It should be noted
that ApoE polymorphism may be a factor in predicting the
effect of EPT on cognitive functioning in postmenopausal
period.
P1-45
METABOLIC MONITORING OF CHILDREN ON
ANTIPSYCHOTICS: A NATIONAL SURVEY OF CHILD
PSYCHIATRISTS
Lead Author: Jennifer McLaren, M.D.
Co-Author(s): Mary F. Brunette, M.D., Gregory McHugo,
Ph.D., William B. Daviss, M.D.
SUMMARY: Objective: Identify factors related to child
psychiatrists' compliance with guidelines for monitoring
metabolic side effects among children taking second
generation antipsychotics (SGA). Background: The use of
SGA in children and adolescents has been rapidly expanding.
These medications can cause significant metabolic side
effects, to which youth are especially vulnerable, such as
diabetes mellitus and hyperlipidemia. The American
Psychiatric Association, American Diabetes Association and
the American Academy of Child and Adolescent Psychiatry
recommend routine monitoring of fasting blood glucose
(GLUC) and fasting lipid profiles (LIP). Past research has
suggested that prescribers do not comply with monitoring
recommendations, but factors related to compliance with
monitoring are poorly understood. This study surveyed a
nationwide sample of child psychiatrists regarding their
compliance with monitoring for metabolic side effects in
children and adolescents treated with SGA. Methods: An
anonymous online survey was sent to 4,144 child
psychiatrists throughout the United States. The survey
assessed physician's knowledge and attitude about
metabolic monitoring in patients treated with SGA.
Physician compliance with metabolic monitoring was based
on survey respondents reported monitoring frequency of
GLUC and LIP. Barriers to this monitoring were also
assessed. Separate multiple linear regression models were
used to examine the independent associations of such
variables with estimated average annual tests of GLUC and
67
AMERICAN PSYCHIATRIC ASSOCIATION
the thalamus nuclei based on functional connectivity. The
segmentation map was consistent with well-known
histological atlas. ANOVA with post-hoc Tukey HSD test
demonstrated that each connection has distinct profile
(p=.000) and it validated this method. Conclusions: This new
automated non-invasive technique provides reliable and fast
connectivity-based classification of the thalamus in
individuals for better treatments and also free from
operators' bias.
P1-47
TOWARD CULTURALLY APPROPRIATE SUICIDEPREVENTION LAWS IN EAST ASIA: A SOCIOCULTURAL,
HISTORICAL, AND LEGAL PERSPECTIVE
Lead Author: Justin Chen, M.D.
Co-Author(s): Kevin Chien-Chang Wu, M.D., LL.B., LL.M.,
Ph.D.
SUMMARY: Rising suicide rates have led to the recent
drafting of suicide prevention laws in several East Asian
countries. Yet the appropriate role of law in reducing
suicides is unclear. Exploring the historical, sociocultural,
and legal precedents regarding suicides in the East versus the
West may help shape public policies aimed at reducing
suicide rates. This project attempts to compare and contrast
the historical evolution of societal, religious, and legal
responses to suicide in East Asia versus the West. A history of
suicide in East Asia and the West is reviewed, with a specific
emphasis on the use of law. The role of stigmatization and
criminalization in suicide prevention in each of these
cultures is discussed. Finally, a culturally appropriate suicide
prevention law for East Asian countries is proposed. In
contrast with the West, suicide in Confucian-based society
was never absolutely condemned, but instead continued to
retain a socially accepted role in certain circumstances.
Recent studies suggest that the factors contributing to
suicide in East Asian countries appear to differ from those in
the West. Culturally appropriate suicide prevention laws in
East Asia should focus on erecting physical and psychological barriers to suicide while also increasing alternatives
for people in extreme distress. By appealing to hope and
family ties rather than shame and stigmatization, suicide
prevention laws can be successful in reducing suicidality.
P1-49
PSYCHIATRIC, DEMOGRAPHIC AND LEGAL PREDICTOR
VARIABLES IN COMPETENCY TO STAND TRIAL
DETERMINATIONS
Lead Author: Cheryl Paradis, Psy.D.
Co-Author(s): Cheryl M. Paradis, Psy.D., Elizabeth Owen,
Ph.D., Linda Z. Solomon, Ph.D., Ben Lane, B.A., Chinmoy
Gulrajani, M.D., Michael Fullar, M.D., Alan Perry, Ph.D.,
Sasha Rai, M.D., Tammy Levi, M.D.
SUMMARY: Introduction: This study assessed psychosocial
and legal characteristics of 200 defendants referred for
competency to stand trial (CST) evaluations. Methods: Data
were examined from an archival sample of CST reports.
Results/Conclusions: Fifty-seven defendants were immigrants and 18 were seen with interpreters. One hundredand-six were charged with felonies. The examiners
diagnosed 114 with psychotic disorders and opined that 104
were incompetent. Compared to those deemed competent,
the defendants deemed incompetent had a significantly
higher rate of psychiatric hospitalizations (80% vs 63%), χ2
(1, N =199) = 6.81, p = .007) and psychotic diagnoses (72% vs
41%), χ2 (1, N = 200) = 19.58, p = .000) and significantly lower
incidence of reported substance abuse (58% vs 79%), χ2 (1, N
= 200) = 10.58, p = .001.) There was a trend towards
significance for defendants seen with interpreters to be
deemed not competent compared to those who did not need
interpreters.
P1-48
AUTOMATED THALAMUS CLASSIFICATION BASED ON
BRAIN CONNECTIVITY USING STOCHASTIC
TRACTOGRAPHY
Lead Author: Taiga Hosokawa, M.D., Ph.D.
Co-Author(s): Tom Ballinger, Sylvain Bouix Ph.D., Marek
Kubicki Ph.D., Robert W. McCarley M.D., Martha E. Shenton
Ph.D., Carl-Fredrik Westin
SUMMARY: Background: Reliable anatomical definition and
stereotactic precision of deep brain nuclei targets are crucial
in clinical settings, since many functional diseases such as
depression, Parkinson disease; essential tremor and dystonia
are neurosurgically treated, including by applying deep brain
stimulation to the appropriate functional area. Atlases of
deep brain nuclei are mostly derived from post-mortem
studies since no imaging technique provides sufficient
contrast to identify distinct nuclei in living human. However,
individual anatomical differences have made mapping
problematic. Especially, the thalamus which all of the sensory pathways project to the cortex through needs precise
localization. More importantly, not only histological
boundaries, but also connectivity-based localization of the
thalamus has been demanded. Methods: We used diffusion
tensor magnetic resonance imaging (DT-MRI) to extract
white matter tracts in living human brain to find connectivity
between the thalamus and cortical targeted regions. We
produced novel stochastic tractography algorithm to overcome the shortcoming of DT-MRI which has been unable to
trace pathways into gray matter. We applied this to eighteen
healthy subjects and compared DTI indices including mean
FA, Trace, axial diffusivity and radial diffusivity within each
connection. Results: This method enabled classification of
P1-50
IDENTIFYING EATING-DISORDER-PATIENTS AMONG
PSYCHIATRIC OUTPATIENT POPULATION: CORRELATES
OF CLINICAL PRESENTATIONS
Lead Author: Mei-Chih Meg Tseng
Co-Author(s): Chin-Hao Chang Ph. D., Hsi-Chung Chen M.D.,
Ph. D., Kwan-Yu Chen M.D., Shih-Cheng Liao M.D., Ph. D.
SUMMARY: Objectives: EDs have been reported to be a
hidden morbidity in prior research, and individuals with EDs
seek help more often with the presentations of emotional
problems than eating/weight problems. This study aimed to
investigate the factors associated with clinical presentations
of non-eating/weight problems in patients with eating
disorders (EDs). Methods: Sequential attendees aged 18-45
without overt psychotic symptoms were invited to participate a two-phase survey for EDs at the psychiatric outpatient
clinics in a university hospital. Each participant completed
the paper form SCOFF and received an interview blindly
using the ED Module of the Structured Clinical Interview for
DSM-IV-TR Axis I disorders (SCID). We adopted loosened
criteria for ED diagnosis, i.e.: patients were not required to
meet the anorexia nervosa criteria for amenorrhea, the
frequency and duration criteria of binge-eating and/or
compensatory behaviors for bulimia nervosa, and the
frequency and duration criteria of binge-eating for binge
eating disorder. Patients diagnosed as EDs were invited to
receive the Structured Interview for Anorexia and Bulimia
68
2014 INSTITUTE ON PSYCHIATRIC SERVICES
5min post first-dose. The maximum mean difference was 3.0
msec with the upper bound of 95% CI of 4.6 msec. As a
positive control, the lower one-sided 95% CI for moxifloxacin
effect was >5 msec at all 4 predefined post-dose time points.
CONCLUSIONS: No clinically relevant change in QTc was
seen with multiple-doses of inhaled loxapine in this
population of healthy volunteers. The largest placeboadjusted, baseline-corrected QTc based on individual
correction method was <10 msec threshold. Data suggest
that inhaled loxapine is not associated with cardiac repolarization liability. Clinicaltrials.gov identifier: NCT01854710
and Mini International Neuropsychiatric Interview, and
completed several self-administered questionnaires. We also
recorded their main reasons to seek for psychiatric help by
chart review methods. Clinical and demographic characteristics of both groups (patients presented with eating/weight
symptoms vs. patients presented with non-eating/weight
symptoms) were compared. Results: A total of 2140 patients
(1306 women, 61%) completed both the SCOFF questionnaire screening and the SCID. Of them, 348 patients (295
women) were diagnosed with a current ED with a prevalence
rate of 22.6% and 6.4% for women and men, respectively.
The top three common reasons seeking for psychiatric help
were eating/weight problems (46.8%), emotional problems
(42.7%), and sleep disturbances (19.0%). One hundred and
ninety-one patients with EDs (166 women, 86.9%) completed
the comorbidity general psychopathology, and functional
impairment assessments. ED patients with fewer educational years, less severe degree of binge-eating, diagnoses
other than anorexia nervosa or bulimia nervosa, more cooccurring psychiatric diagnoses, and more severe degrees of
anxiety, depression, impulsivity and functional impairment
were more likely to present themselves with non-eating/
weight problems at the psychiatric outpatient clinic. There
were no statistical differences of the degree of body image
concern and body weight between patients with and without
presentation of eating problems. Conclusion: ED patients
with more co-occurring psychiatric conditions and poorer
functioning were less likely to report their eating problems.
This hidden morbidity could hinder the management of
patients with complex psychopathology if not being
identified clinically.
Funding: This study was funded by Alexza Pharmaceuticals. Medical
writing support was provided by Karen Burrows, MPhil, of Excel
Scientific Solutions and was funded by Teva Pharmaceuticals.
P1-53
PSYCHIATRISTS’ OPINIONS ON BARRIERS TO
PROVIDING INTEGRATED CARE SERVICES
Lead Author: Krista Ferretti, B.S.
Co-Author(s): Ruth Shim, MD, MPH; Cathy Lally, MSPH;
Rebecca Farley, MPH; Chuck Ingoglia, MSW; Benjamin G.
Druss, MD, MPH
SUMMARY: Objectives: To evaluate the perspectives of
psychiatrists actively working in Community Mental Health
Centers (CMHCs) on their ability to address chronic illness in
their patients. Background: Patients with serious mental
illnesses are more likely to die early of chronic physical
disease than patients without serious mental illness,
especially those patients who receive public mental health
treatment. In recent years, there has been growing interest in
expanding CMHCs to provide primary care services to their
patients. It is crucial to address the limitations that
psychiatrists deal with in delivering integrated care, in order
to effectively improve health outcomes for patients with
serious mental illnesses. Methods: A convenience sample of
248 psychiatrists in CMHCs responded to an online survey
sent out by the National Council for Behavioral Health and
the National Alliance on Mental Illness (NAMI). Survey
questions assessed whether primary care workers were
employed at their organization, what types of barriers they
encountered in delivering primary care, what types of
primary medical services were offered, and what percentage
of patients received those services. Using SAS 9.3 statistical
software, we analyzed descriptive statistics. Results: 38.6% of
psychiatrists surveyed reported they provide primary care
services, and 24.8% employ primary care workers. The most
common barriers that were considered by psychiatrists in
CMHCs were physical space limitations, workforce limitations and reimbursement issues. More than 50% of
psychiatrists reported they provide screenings for common
health issues, with 55.9% screening for blood pressure, 58.0%
for obesity, 63.0% for cholesterol, and 60.1% for diabetes.
Very few psychiatrists reported they provide medication for
any of the health issues they screen for, with 7.1%
prescribing medication for blood pressure, 5.0% for
cholesterol/lipids, and 5.9% for diabetes. Psychiatrists
surveyed did note that other clinicians working at CMHCs
tend to prescribe medications at higher rates than psychiatrists (26.9% for blood pressure, 26.1% for cholesterol/lipids,
and 24.5% for diabetes). Conclusions: In general, psychiatrists in CMHCs perform screenings for chronic health
conditions; however they face major challenges in managing
patients that screen positive for these conditions. The
findings of this study reveal that several barriers still exist to
psychiatrists' attempts to provide improved medical care to
their patients. One study limitation is the use of a
P1-51
WITHDRAWN
P1-52
A RANDOMIZED, PLACEBO-CONTROLLED REPEAT-DOSE
THOROUGH QT STUDY OF INHALED LOXAPINE IN
HEALTHY VOLUNTEERS
Lead Author: James V. Cassella, Ph.D.
Co-Author(s): Daniel A Spyker, Ph.D, M.D.; Paul Yeung, M.D.,
M.P.H.
SUMMARY: OBJECTIVE: To investigate potential effects on
cardiac repolarization (QT-interval) of 2 consecutive doses of
inhaled loxapine administered 2hr apart, in relation to
placebo and active control (NCT01854710). BACKGROUND:
Single-dose administration of inhaled loxapine via the
Staccato® system was not associated with clinically relevant
QT prolongation, but the effect of repeat dosing of inhaled
loxapine on QTc prolongation has not been previously
studied. DESIGN/METHODS: This randomized, doubleblind, positive-controlled, cross-over study was conducted in
healthy volunteers (aged 18-65y). Each subject received: 2
doses of inhaled loxapine (10mg)+oral placebo; 2-doses
inhaled placebo+oral placebo; or 2 doses inhaled
placebo+oral moxifloxacin (400mg) [positive control], with
>3-days washout between treatments. Inhaled doses were
spaced by 2hr. Primary outcome was maximum effect of
inhaled loxapine on QTc interval duration vs. placebo at 12
preselected time points across the 24-hr post dose interval.
RESULTS: Of 60 enrolled subjects (33.8y; 52% male), 45
(75%) completed the study. Inhaled loxapine did not
increase QT interval across 24hr post-dose follow-up, as
demonstrated by a maximum mean increase in the placebocorrected change in QTc from baseline of 4.04 msec at 2hr
69
AMERICAN PSYCHIATRIC ASSOCIATION
P1-55
INHALED LOXAPINE AND LORAZEPAM IN HEALTHY
VOLUNTEERS: RESULTS OF A RANDOMIZED, PLACEBOCONTROLLED DRUG-DRUG INTERACTION STUDY
Lead Author: Dr Daniel Spyker, M.D.,Ph.D
CoAuthors: James V Cassella, Ph.D., Randall R. Stoltz,
M.D.,Paul P. Yeung, M.D., M.P.H.
SUMMARY: OBJECTIVE: To compare the safety and
pharmacodynamic effects of single-dose inhaled loxapine
and intramuscular (IM) lorazepam compared with each
agent administered alone (NCT01877642). BACKGROUND:
Inhaled loxapine administered via the Staccato® system is
an effective treatment for agitation in patients with
schizophrenia or bipolar I disorder. Lorazepam is a
commonly used treatment for agitation that is often
concomitantly administered with other treatments, but a
lorazepam interaction with inhaled loxapine has not been
previously studied. DESIGN/METHODS: This randomized,
double-blind, cross-over study was conducted in healthy,
non-obese volunteers (aged 18-50y). Primary endpoints were
the maximum effect (i.e. minimum value) and area under the
curve (AUC) from baseline to 2hr post-treatment value in
respirations per minute and pulse oximetry between
treatment groups: concomitant inhaled loxapine 10mg+IM
lorazepam 1mg (Treatment A) vs. inhaled loxapine 10mg+IM
placebo (Treatment B), or vs. IM lorazepam 1mg + Staccato®
placebo (Treatment C). LS-mean [90% CI] for ratio of
Treatment A vs. either Treatment B or Treatment C were
derived. Equivalence was confirmed if the 90% CI of the
ratios fell within 0.8-1.25 range. All subjects were exposed to
Treatments A-C in random order, with 3-day washout
between treatments. Other pharmacodynamic safety
measures included effects on blood pressure (BP), heart rate,
and sedation (100mm visual analog scale). Adverse events
(AEs) were also recorded. RESULTS: All 18 enrolled subjects
(mean 20.4y; 61% male) completed the study. No significant
interaction was seen with inhaled loxapine +IM lorazepam
(Treatment A) on respiration or pulse oximetery vs. either
agent alone (vs. Treatment B or C) throughout the 12hr postdose period, as 95% CI of ratios of AUC and Cmin fell within
0.80-1.25 range supporting equivalence. BP and heart rate
were also unchanged throughout 12hr post-dose period with
inhaled loxapine+IM lorazepam vs. either agent alone. VAS
sedation was significantly lower 2hr post-dose with inhaled
loxapine+IM lorazepam vs. IM lorazepam alone. However,
coadministered inhaled loxapine+IM lorazepam was equivalent for sedation vs. inhaled loxapine alone throughout 12hr
post dose period. There were no deaths, serious AEs, or
premature discontinuations due to AEs. No treatmentemergent AEs considered related to study drug were
reported. CONCLUSIONS: In this population of healthy
volunteers, no effects on respiration pharmacodynamics or
vital signs were seen when inhaled loxapine was administered in combination with IM lorazepam compared with
each drug taken alone. Effects on sedation were expected
with each drug and the combination did not result in any
significant change in sedation vs. inhaled loxapine alone.
Funding: This study was funded by Alexza Pharmaceuticals.
Medical writing support was provided by Karen Burrows,
MPhil, of Excel Scientific Solutions and funded by Teva
Pharmaceuticals.
convenience sample of psychiatrists, which does tend to
limit generalizability. However, despite this limitation, this
study helps to quantify challenges and identify barriers to
improve integrated care services in CMHCs. Starting points
include addressing space limitations and providing the
adequate workforce to provide integrated services.
P1-54
THE INTENSIVE WELLNESS PROGRAM: AN INTEGRATED
MEDICAL AND BEHAVIORAL HEALTH APPROACH TO
HIGH COST PRIMARY CARE PATIENTS
Lead Author: Jeffrey Levine, MD
Co-Author(s): Oneira Torres, M.A., Mercedes Nunez de Cruz,
CHW, Carla Cruz, B.A., Rachel Mayers, M.A., Rebecca Riemer,
B.A., Andreas Evdokas, Ph.D., Sasidhar Gunturu, M.D., Judd
Anderman, M.A., M.A., Ali Khadivi, Ph.D.
SUMMARY: Objective: A relatively small number of patients
account for a disproportionate share of healthcare costs.
Such patients most often suffer from mental illness, substance abuse, social disarray, and chronic medical conditions. This project was designed to identify, assess, engage,
and care for multi-morbid individuals in an inner city
primary care center. The major objective was to prevent
unnecessary hospitalizations. Method: Primary care patients
with both chronic mental and behavioral health diagnoses
and likely to be hospitalized were identified via a risk stratifycation tool, Patients-at-Risk-of-Rehospitalization (PARR).
Patients underwent full biopsychosocial evaluation and were
engaged in enhanced, culturally competent, co-located
healthcare with health, mental health, case management and
social service components for up to one year. In pre/post
quasi-experimental design, inpatient, outpatient, and emergency utilization were examined one year before and one
year after initiation of the program. Results: Among 113
patients, mean age was 48(9) years; 55% were female; 42%
Spanish speakers; 66% had not completed high school. Over
half had a history of bipolar illness, schizophrenia and/or
substance abuse. Most frequent medical illnesses were
hypertension (70%); diabetes (47%); and asthma (37%).
Nearly one-quarter rated their health as "good to excellent"
and over 90% were "very confident" in their abilities to
manage their illnesses. Mean Montreal Cognitive Assessment score was 20(5), suggesting very significant cognitive
deficits in this population. Hospitalizations decreased: 2.1
(2.4) vs. 1.6 (2.2), p<.01; emergency department visits also
significantly decreased while outpatient visits increased
robustly. Overall, the intervention was calculated to be cost
effective with reduction in healthcare costs of $7,000 (19%)
per patient per year. Conclusion: A strategy to identify high
risk multi-morbid patients within primary care and then to
offer enhanced combined medical, psychiatric, and cultureally competent social support appears to be cost effective.
Such inner city patients frequently misperceive their health
status and have significant cognitive impairments that may
interfere with self-care. Larger studies are needed to confirm
these findings.
70
2014 INSTITUTE ON PSYCHIATRIC SERVICES
performed to identify characteristics predictive of a depresssive disorder in this population. Results: Among 6,112
patients studied, a total of 812 (13.3%) patients reported
being diagnosed with a depressive disorder while 5,300
(86.7%) reported no such diagnosis. Patients with a depresssive disorder tended to be younger (59 vs 63 years, p<0.001),
female (17% vs 8%, p<0.001), unmarried (47% vs 32%,
p<0.001), and be unemployed with lower salaries. They were
more likely to be uninsured with financial barriers to medical
care (13% vs 5%, p<0.001). They also had higher rates of
obesity (33% vs 25%, p<0.001), smoking (40% vs 25%,
p<0.001), high-risk sexual behavior (3% vs 1%, p=0.009),
diabetes (22% vs 15%, p<0.001), prior heart attack (17% vs
12%, p<0.001), prior stroke (11% vs 5%, p<0.001), and anxiety
(49% vs 4%, p<0.001). In multivariate analysis, presence of
anxiety was the strongest predictor of a depressive disorder
(OR 14.94, 95%CI 10.87-20.54). Other independent determinants of a depressive disorder included female gender (OR
2.78, 95%CI 1.82-4.24), marital status, employment, and
diabetes (OR 1.77, 95%CI 1.17-2.67). Conclusions: Female
gender, diabetes, marital status, employment, and anxiety
are independently associated with presence of a depressive
disorder among U.S. veterans. The presence of anxiety
should be strongly considered in depression screening of
veterans as these two disorders tend to co-exist.
POSTER SESSION 2
P2-1
MENTAL HEALTH INTEGRATION IN SCHOOL-BASED
HEALTH CENTERS: CHALLENGES AND SUCCESSES
Lead Author: Roya Ijadi-Maghsoodi, M.D.
Co-Author(s): Sisi Guo, M.A., Karen Lai, M.P..H, M.S., Sheryl
Kataoka, M.D., M.S.H.S.
SUMMARY: Introduction: Many children in the US, especially ethnic minority youth, do not have access to quality
healthcare. School-based health centers are in many ways an
ideal way to deliver care to youth who may otherwise not
receive it. They have been shown to reduce access-to-care
barriers, improve educational outcomes for vulnerable
youth, and affect fundamental social determinants of health.
The Los Angeles Unified School District recently developed
14 Wellness Centers, unique school-based health centers
providing comprehensive care that are located in areas of
Los Angeles with the worst health and mental health
outcomes. These centers go beyond the traditional schoolbased health center model in an effort to provide a health
home for underserved youth and their families and
community members. This study examines how these
Wellness Centers integrate mental health care with health
and educational services, and identifies challenges and innovations across sites. Methods: We conducted 43 qualitative
key informant interviews of health providers, mental health
counselors, and coordinators at each Wellness Center.
Atlas.ti was used to code data for main themes and subthemes. Results: The interviews revealed key successes and
challenges across the Wellness Centers within the major
domains of operations, partnership, and engagement with
youth, parents, and teachers. We discovered several barriers,
such as barriers to sharing information due to privacy laws,
and challenges engaging families due to fear and
intimidation. We found several novel methods of providing
care, including shared medical and mental health appointments. Discussion: We will discuss important considerations
involved in mental health integration in school-based
settings, strategies for overcoming barriers to integration,
and recommendations and next steps to improving these
innovative methods of care delivery.
P2-3
THE PRIZE IS RIGHT: A LOW-COST INCENTIVE INTERVENTION FOR FIRST EPISODE PSYCHOSIS PATIENTS
Lead Author: Nicole F Mehdiyoun, M.A.
Co-Author(s): Emily Liffick, M.D., Ashley Overley, M.D.,
Emmalee R Metzler, B.A., David E Spradley, R.N., Alan Breier,
M.D.
SUMMARY: Appointment non-adherence ("no-shows") is
common in mental health settings and may lead to symptom
exacerbation and poor prognosis in patients diagnosed with
schizophrenia spectrum disorders. Additionally, lost revenue
and staff productivity reduces the financial solvency of
clinics and the continued ability to provide services when
no-show rates are high. Contingency management (CM)
programs, interventions that apply operant conditioning
principles to specific behaviors for positive reinforcement
with the goal of promoting a clearly defined behavior, have
been most widely studied in substance abuse treatment.
Incentives for attending medical management appointments
were offered to first episode psychosis (FEP) patients in a CM
program termed "The Prize is Right." Upon attending each
appointment, patients drew a ticket with a 50% probability
that a ticket resulted in a prize. For individuals who did not
win a prize, a small piece of candy was offered. Prizes were
offered in multiple sizes: -Small (worth approximately $1),
Medium ($5), Large ($20), and Super ($50)—with the
chances of winning a specific sized prize inversely related to
its cost. It was anticipated that "The Prize is Right" would
provide a relatively low-cost approach to improving "noshow" rates in our clinic. Within the first two months, CM
decreased the "no-show" rate (26.5% vs 32%). Data at six
months will be presented. There is a paucity of information
about the effectiveness of CM in improving clinical
outcomes in FEP. These findings suggest contingency
management using incentives may be an affordable option
to increase treatment adherence, which may improve the
long-term functional and recovery outcomes in FEP.
P2-2
PREDICTORS OF DEPRESSIVE DISORDERS AMONG U.S.
VETERANS
Lead Author: Roopali Parikh, M.D.
Co-Author(s): Juan D. Oms, M.D., Yusef Canaan, M.D., and
Mario Cuervo, M.D.
SUMMARY: Background: Depression, one of the most
common and expensive mental disorders, costs the U.S.
approximately $66 billion annually. Veterans diagnosed with
depression account for slightly more than 14 percent of the
total. We sought to describe the demographic and clinical
characteristics of U.S. veterans reporting diagnosis of a
depressive disorder and determine what characteristics were
independently associated with depressive disorders in this
population. Methods: The 2008 Centers for Disease Control's
Behavioral Risk Factor Surveillance Survey was utilized to
identify a cohort of 6,112 U.S. veterans that reported the
presence or absence of a diagnosed depressive disorder.
Demographic data and clinical history were recorded in
these patients. Univariate and multivariate analyses were
71
AMERICAN PSYCHIATRIC ASSOCIATION
SUMMARY: Substance abuse, a major comorbid condition in
first episode psychosis (FEP), is challenging to measure and
to intervene successfully. TimeLine FollowBack (TLFB), a
validated and innovative research and clinical tool for
substance consumption, has rarely been used in early
psychosis. Objective: To describe the use of TLFB and the
profile it generates for evaluation of and interventions in
substance use in a sample of patients being treated for a FEP
following 2 years of treatment and follow-up in an early
intervention service. Method: Every 3 months, substance use
information is collected via a computerized version of TLFB,
as part of a standardized clinical evaluation of outcome, to
document the use of alcohol and drugs on a daily basis. TLFB
is administered with patients who have past evidence of
consumption and agree to complete it with a trained evaluator. Results: Of the 62 patients, who had completed 3 years
of treatment and follow-up and had a history of alcohol andor substance abuse, 50 (81%) patients (M=42, F=8 ) agreed to
complete TLFB. Profiles of patients over repeated measurements will be presented and implication for clinical use
discussed. Thirty-one patients (M=16 , F=15 ), with no
history of consumption in the previous 12 months, did not
complete TLFB. Conclusion: TLFB may have research and
clinical utility in young patients with psychosis and comorbid substance use.
P2-4
CERTIFICATION EXAM DEVELOPMENT IN PUBLIC
PSYCHIATRY: PROCESS AND OUTCOMES
Lead Author: Michael Weinberg, Ed.D.
Co-Author(s): Anthony Carino, M.D.
SUMMARY: Background: The American Association of Community Psychiatrists developed and validated a certification
exam in community psychiatry as part of a larger effort
aimed at certification in community and public psychiatry.
This process formalizes the knowledge and skills necessary
to practice community psychiatry, supports community and
public psychiatry fellowships and builds training interest in
the field. Methods: The scholarship and training committee
of the AACP board of directors contacted experts in the field
to write questions in each of 10 domains in community
psychiatry. 37 experts developed 259 questions which were
revised according to guidelines established in the field of
psychometrics as well as for clarity. The exam was then
piloted with 73 examinees consisting of 25 experts, 36 early
career community psychiatrists, and 12 PGY4 residents who
were contacted through AACP and public psychiatry fellowship alumni list serves as well as residency training directors.
The test was uploaded on an online platform and made
available to examinees through a secure link. Test statistics
based on classical test theory were used to determine (1) how
well the item discriminated between experts and PGY4s as
well as high and low achieving early career psychiatrists and
(2) the difficulty of the items for the entire sample as well as
each group of examinees. The internal structure of the test
was evaluated using factor analysis, and internal reliability
was assessed with Cronbachs alpha. A passing score was
decided using the contrasting group method to determine
the intersecting point between the three groups' performance. Results: Each item was reviewed to determine its functioning. Items whose difficulty statistic fell at or below
chance level (.25) or greater than .90 were eliminated, and
items that poorly discriminated between experts and PGY4
residents or within the candidate group were eliminated.
Overall 124 items were discarded leaving 135 items. A oneway ANOVA demonstrated the performance of the three
groups was different [F (2, 70) = 5.43, p=0.006] with experts
and early career psychiatrists performing better than PGY4
residents. The factor analysis did not reveal a discernible
internal structure of the test. Reliability was satisfactory
(α=.88). All of the members of the expert group passed, as
did 67% of the early career psychiatrists. In the PGY4 group
33% passed. Conclusions: These results suggest that public
psychiatrists have skills and knowledge distinct from
novices. It is concerning that the factor analysis did not
reveal an internal structure of the test that is congruent with
the 10 domains in community psychiatry. This may be due to
the small sample or multidimensionality in the items
resulting from the complicated nature of the filed. Test
development is inherently iterative and additional field tests
are needed with more examinees representing the plurality
of psychiatry to fully establish the test's validity.
P2-6
TRAUMA HISTORY IN HIV POSITIVE AFRICAN AMERICAN
WOMEN: EFFECTS ON PSYCHIATRIC SYMPTOM
SEVERITY AND COPING
Lead Author: Julie Rae Brownley, Ph.D.
Co-Author(s): Roger D. Fallot, Ph.D., Seth S. Himelhoch, M.D.,
M.P.H.
SUMMARY: Background: While rates of HIV among men
have decreased, HIV infection among women is on the rise,
particularly in African American women. HIV-infected
women have up to 5 times the risk of developing PTSD
compared to the general population. HIV positive individuals with a concurrent diagnosis of PTSD have poorer HIVrelated outcomes, however the prevalence and impact of
PTSD on HIV-infected African American women seeking
mental health treatment is unknown. The aim of this study is
to examine the associations between trauma symptoms with
psychiatric symptom severity and psychological and religious coping strategies in African American women living
with HIV who are seeking mental health treatment at a
community mental health center. Methods: This is a crosssectional study of 235 HIV-positive African American women
attending an intensive case management program affiliated
with an urban community mental health clinic. Research
assessments were conducted by trained research assessors
and included the PTSD Symptom Scale, Brief Symptom
Inventory, SF-12, Brief COPE and Brief RCOPE. A cutoff of 21
on the PTSD Symptom Scale (PSS>21) was used as a
meaningful measure of PTSD. Bivariate analyses were conducted to evaluate associations between the outcomes of
interest PSS>21 versus PSS<21 and 1) psychiatric severity; 2)
coping strategies and 3) religious coping strategies. Results:
The average age was 43 years (mean±sd(43.3 ± 8.9)) and
90% were unemployed. On average, participants reported
being infected with HIV for 11 years (mean ±sd(11.25 ±
7.7)). Participants reported between 4-5 traumatic events
over their life-time (4.5±2.4). Thirty-six percent reported
symptoms consistent with PTSD (PSS=18.2±12.7). Most
participants reported a moderate severity of mental health
P2-5
« TIMELINE FOLLOWBACK »: FEASIBILITY OF USING AN
INNOVATIVE TOOL FOR THE MEASUREMENT OF AND
INTERVENTION IN SUBSTANCE CONSUMPTION IN EARLY
PSYCHOSIS
Lead Author: Marie-Christine Rondeau, B.A.
Co-Author(s): A. Rho, S. Iyer, R. Joober, N. Schmitz, T. Brown,
M, A.K Malla.
72
2014 INSTITUTE ON PSYCHIATRIC SERVICES
symptoms. Women with a PSS≥21, were significantly
more likely to report depression (p Ë‚ .001), and anxiety (p Ë‚
.001) and were more likely to employ negative psychological
(i.e., denial and self-blame) (p Ë‚ .001) and negative religious
coping strategies (p Ë‚ .001). On the contrary, women with a
PSSË‚21, reported relatively low levels of mental health
symptoms and were more likely to rely on positive psychological and religious coping strategies. Conclusions: Over
one third of African American women living with HIV/AIDS
attending an outpatient mental health clinic had symptoms
associated with PTSD. These symptoms were associated with
worse mental health symptoms, and utilization of dysfunctional religious and non-religious coping strategies. These
findings suggest that screening for trauma symptoms among
women living with HIV/AIDS may help to identify the
women with the highest need for mental health services.
Considering the wide overlap of depressive and trauma
related symptoms, depression screening may be necessary
but not sufficient to wholly assess the needs of women living
with HIV/AIDS. Therefore, screening for and treatment of
PTSD in the context of HIV infection is warranted.
symptoms of neurological and psychiatric problems such as
severe headache, seizures, Bell's palsy, encephalopathy,
tremors, night sweats, memory impairment, anxiety,
depression, psychosis, etc.
REFERENCE
1. Bransfield. "The Psychoimmunology of Lyme/Tick-Borne Diseases
and its Association with Neuropsychiatric Symptoms." The Open
Neurology Journal. 2012:6 88-93
2. Fallon and Nields. "Lyme Disease A Neuropsychiatric Illness." Am J
Psychiatry 151:11. Web. November 1994 pp.1571-1580
3. Fritzsche. "Georgraphical and seasonal correlation of multiple
sclerosis to sporadic schizophrenia." International Journal of Health
Geographics. 2002 1:5
4. Fritzsche. "Seasonal Correlation of sporadic schizophrenia to Ixodes
ticks and Lyme borreliosis." International Journal of Health Georgraphics
2002 1:2
5. Miklossy. "Chronic or Late Lyme Neuroborrelipsis: Analysis of
Evidence Compared to Chronic or Late Neurosyphilis." The open
Neurology Journal. 2012:6 146-157
P2-8
FACTITIOUS HYPOGLYCEMIA: A CASE REPORT
Lead Author: LAIMA SPOKAS, M.D.
Co-Author(s): Mary J.Bapana M.D, Asghar Hossain M.D.
SUMMARY: Introduction: Hypoglycemia, in an insulin
dependent diabetic patient, is a fairly common presentation
at the ER. However, the differential diagnosis changes when
hypoglycemia is seen in an apparently healthy nondiabetic
patient, and warrants extensive evaluation to determine the
cause of the hypoglycemia. This new differential includes
Insulinoma and self-induced hypoglycemia caused due the
surreptitious or inadvertent use of Insulin or the insulin
secretagogues like sulfonylurea and meglitanides but not
from the use antidiabetic medications like metformin which
are insulin sensitizing. Objective: The objective of this article
is to report a case of self-induced hypoglycemia and to
review available literature obtained from PubMed, PMC,
UpToDate and Google; on the investigative methods for
detection of sulfonylurea, and the association of factitious
hypoglycemia with borderline personality disorder.
Discussion: Review of literature showed that factitious
hypoglycemia due to insulin over dose is a fairly common
especially in diabetic patients. However, we have seen there
has been an increase in cases of hypoglycemia due to
surreptitious or inadvertent use of sulfonylurea. It has been
observed that it is most common seen in females working in
the medical profession or having a close relative with
diabetes. This could also, inadvertently, be due to the
dispensation of wrong medication due to similar sounding
names or medications that look similar to the sulfonylurea. It
was also found that there are numerous assays available to
identify sulfonylurea but not all assays identify the newer
sulfonylurea, therefore a negative screen does not exclude
sulfonylurea. Review of literature revealed to us case reports
of and articles suggesting an association between factitious
hypoglycemia and Borderline personality disorder, as was
observed among our patients. Conclusion: In conclusion, we
have found that self-induced hypoglycemia is a common
presentation at the ER. The kind of assay used is essential as
not all assays identify all of the newer sulfonylurea. The time
line of when the assay is done is essential, as the half-life of
the sulfonylurea varies. Finally factitious hypoglycemia has a
strong association with borderline personality disorder.
P2-7
PSYCHOSIS IN LYME DISEASE
Lead Author: LAIMA SPOKAS, M.D.
Co-Author(s): Vandana Kethini, M.D, Irmute Usiene, M.D,
Natasha Baron M.D, Alice Shin
SUMMARY: OBJECTIVE This case report is to demonstrate a
patient who was diagnosed with Lyme disease presenting
with psychiatric problems to an emergency department.
Additional thoughts were put on regarding Lyme disease and
its effect on the brain. METHODS Mainly web searches on
articles with the keywords: Lyme disease, psychosis, and
psychiatry. CASE Mr. E is a previously healthy 53-year-old
Caucasian male living in New Jersey. Previously the patient
worked as a professional pilot. He does not have history of
psychiatric illness, psychiatric hospitalizations, and seeing a
psychiatrist. When the patient started experiencing the
worsening of forgetfulness he went to a family physician and
diagnosed with Lyme disease. He was put on doxycycline but
it only minimally improved his symptoms. The patient's
brother and sister got concerned and brought the patient to
the psychiatric emergency department. In the emergency
department patient reported auditory hallucinations. After
evaluation the patient admitted voluntarily and started on
olanzapine and escitalopram. A week after the start of the
treatment the patient showed significant improvement of his
symptoms. After a month of admission in an acute
psychiatric unit he was transferred to an intermediate care.
The patient is still hospitalized for a continuous care and for
the final goal of getting to be discharged to home.
CONCLUSION It is necessary for a psychiatrist to exclude all
the possible medical causes before treating the patient with
psychiatric medications. But in case of Lyme disease patients
need concurrent medical and psychiatric treatments to
improve their neuropsychiatric symptoms. It would be
indispensible for psychiatrists to consider Lyme disease in
their differential diagnosis when a patient without any
history of psychiatric illness presents with disturbing
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AMERICAN PSYCHIATRIC ASSOCIATION
health, including its applications, strengths, limitations, and
evidence base (Lal & Adair, 2014, Psychiatric Services).
Methods: The rapid review approach, an emerging type of
knowledge synthesis, was used in response to a request for
information from policy makers. MEDLINE was searched
from 2005 to 2010 by using relevant terms. The search was
supplemented with a general Internet search and a search
focused on key authors. Results: A total of 115 documents
were reviewed: 94% were peer-reviewed articles, and 51%
described primary research. Most of the research (76%)
originated in the United States, Australia, or the Netherlands.
The review identified e-mental health applications addressing four areas of mental health service delivery: information
provision; screening, assessment, and monitoring; intervention; and social support. Currently, applications are most
frequently aimed at adults with depression or anxiety
disorders. Some interventions have demonstrated effectiveness in early trials. Many believe that e-mental health has
enormous potential to address the gap between the
identified need for services and the limited capacity and
resources to provide conventional treatment. Strengths of emental health initiatives noted in the literature include
improved accessibility, reduced costs (although start-up and
research and development costs are necessary), flexibility in
terms of standardization and personalization, interactivity,
and consumer engagement. Conclusions: E-mental health
applications are proliferating and hold promise to expand
access to care. Further discussion and research are needed
on how to effectively incorporate e-mental health into
service systems and to apply it to diverse populations.
P2-9
ACCESS AND USE OF MOBILE TECHNOLOGIES,
INTERNET, AND SOCIAL MEDIA AMONG YOUNG PEOPLE
RECEIVING SERVICES FOR A FIRST EPISODE OF
PSYCHOSIS
Lead Author: Shalini Lal PhD
Co-Author(s): Ashok Malla, MD, FRCPC
SUMMARY: Introduction: Web-based and mobile technologies offer a promising avenue to improve access and
quality of youth mental health service delivery. However,
limited research has been conducted on whether these types
of technologies are: feasible for delivering mental health
services to youth, acceptable to youth, and effective (and
cost-effective) in reducing the disabling consequences of
psychotic disorders. Objectives: The purpose of this study is
to explore access and use of mobile technologies, Internet,
and social media among young people recently diagnosed
with a first episode of psychosis and their perspectives of
using these technologies for receiving mental health
information, services and supports. Methods: Intervieweradministered survey with an estimated sample of 60-100
young people between the ages of 18-35 recruited from two
specialized early psychosis programs operating within the
McGill-RUIS network in Montreal, Canada. Results: This
study is currently underway and complete results will be
available at the time of the presentation. Preliminary results
are: 29 participants with a mean age of 25 (SD=3.8), of which
two thirds are males (69%, 20/29) have been recruited into
the study. Most (72%, 21/29) have access to cell phones, the
majority of which have access to smart phones (20/21, 95%).
Most have access to a laptop computer (79.3, 23/29) and
more than half have access to a desktop computer at home
(51.7%, 15/29). The top three internet activities were:
watching videos (100%, 29/29), listening to music (96.6%,
28/29), and searching for information (93.1%, 27/29).
Approximately 55% of the sample had searched for mental
health information on-line in the past year. The most visited
social media site was YouTube (96.6%), followed by
Facebook (82.8%). All participants agreed or strongly agreed
that technology could be used to provide various types of
services and activities including: text messaging for medication and appointment reminders, connecting with peers and
service providers, and receiving mental health-related
information. Conclusions: Preliminary results suggest that
young people are interested in receiving mental health
information, services, and supports via technology. This
research can help to inform the development and testing of
Internet interventions for the first episode psychosis
population.
P2-11
LONG TERM LITHIUM THERAPY RELATED ASYMPTOMATIC HYPERCALCEMIA AND HYPERPARATHYROIDISM:
A CASE REPORT
Lead Author: Bharat Nandu, M.D., M.P.H.
Co-Author(s): Gurjot Singh M.D., Srinivasa Gorle M.D
SUMMARY: Lithium was approved by U.S. FDA for manic
illness in 1970. Lithium induced hyperparathyroidism was
first described in 1973. The management of Lithium induced
Hypercalcemia and hyperparathyroidism has been very
challenging and requires the participation of multiple
specialties. We report a case of 54 year old female who has
history of Bipolar I disorder treated with chronic lithium
therapy. During routine evaluation, pt was found to have
increased serum calcium and PTH levels and lithium level
was within therapeutic range. Serum calcium and PTH levels
remained high even after discontinuation of lithium. Later
on right parathyroidectomy was done and Calcium and PTH
levels became normal.
P2-10
HOW TECHNOLOGY IS TRANSFORMING THE MENTAL
HEALTH CARE SYSTEM: A RAPID REVIEW OF THE
LITERATURE
Lead Author: Shalini Lal PhD
Co-Author(s): Carol Adair, PhD
SUMMARY: Introduction: Innovations in information and
communication technology (ICT) are transforming the landscape of health service delivery. Interest is also increasing in
the application of ICT in mental health care, commonly
referred to as 'e-mental health.' Because of the rapid growth
of the e-mental health field, it is important to stay abreast of
available applications and the evidence of their effectiveness.
Objective: In this presentation, the authors will describe the
methods and results of a published review on e-mental
P2-12
A MIXED METHODS STUDY OF BARRIERS AND FACILITATORS TO COMPETITIVE WORK IN VETERANS WITH
MENTAL ILLNESS: VA SUPPORTED EMPLOYMENT STAFF
PERSPECTIVES
Lead Author: Marina Kukla, Ph.D.
Co-Author(s): Sharon Sidenbender, Amy Strasburger, Jessica
McGlynn, Michelle Salyers
SUMMARY: Background: Veterans with mental illness often
have poor competitive employment functioning, which
contributes to an array of negative psychosocial and financial outcomes. However, the factors impacting vocational
success in the community are not well understood. To
address the gap in the literature, this mixed methods study
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
socio-demographic characteristics, history of suicidal
behavior, clinical diagnosis (based on I.C.D 10 criteria),
severity of illness (based on Clinical Global Impairment
(CGI) score), global assessment of functioning, self-care
ability, Crisis Triage Rating Scale (CTRS) scoring of
dangerousness, cooperativeness and social support. Results:
Hospitalization was associated with being unmarried
(p<0.001), unemployed (p<0.001), being a vagrant (p<0.001),
psychoactive substance use disorder (p<0.001), worse illness
severity (p<0.001), history of suicidal behavior (p<0.001),
dangerousness (p<0.001), uncooperativeness (p<0.001), poor
social support (p<0.001), poor self-care (p<0.001) and poor
psycho-social functioning (p<0.001). On regression analysis,
the predictors of hospitalization were younger age (OR=1.3),
dangerousness (OR=1.7), uncooperativeness (OR =2.5), poor
self care (OR=2.1) and presence of psychoactive substance
use disorder (OR=3.7). Conclusion: The disposition of
patients presenting to the emergency service were predominantly determined by their clinical needs. Development of
local guidelines could facilitate consistency in the matching
of the clinical needs of the patients presenting to emergency
services with the choice of disposition.
investigated the barriers and facilitators influencing employment success in Veterans with mental illness from the
perspective of Veterans Affairs (VA) supported employment
staff and supervisors. Methods: The study utilized a parallel
convergent mixed methods design in which a nationwide
sample of 117 frontline VA supported employment staff and
supervisors participated in an online survey. The first
portion of the survey consisted of 26 potential barriers/
facilitators scored on a 1 to 5 Likert scale, assessing the
degree to which factors were helpful and harmful to work
success. Second, participants were asked to rank the three
most impactful facilitators and barriers. Third, open-ended
questions probed additional factors to garner richer information that was not captured on the Likert scaled survey.
Results: Eighty-seven frontline staff persons and 30 supervisors and upper level managers participated in the study.
Participants had worked an average of 10.2 years (SD=8.7) in
the vocational rehabilitation field and their caseloads
primarily consisted of Veterans with severe mental illness.
Participants identified the most impactful facilitators as
personal motivation, strong job match, and work-related
self-confidence. The most impactful barriers were mental
health, physical health, psychological stress, and cognitive
functioning. Overall, VA supported employment services
were also viewed as a key contributor to positive employment outcomes. Qualitative findings reveal that personal
resources are important to Veterans' employment success,
including transportation, housing, and clothing for job
interviews. In addition, participants highlighted the role of
building strong relationships with employers to effectively
job develop and help Veterans obtain and maintain jobs over
time. In a related vein, addressing employers' stigma related
to hiring Veterans with mental illness and assisting
employers in providing appropriate workplace supports for
Veterans is critical to work success. Conclusions: The
findings of this mixed-methods study are consistent with
previous community-based studies exploring barriers and
facilitators to work. This study adds to our understanding
regarding the key role of employers and building strong
relationships to combat Veteran-related stigma and assisting
the employer to appropriately accommodate and work with
Veterans. In addition, a lack of Veteran resources was
highlighted as a notable barrier that should be further
addressed.
P2-14
CORRELATES OF LENGTH OF HOSPITALIZATION IN A
SUB-SAHARAN PSYCHIATRIC HOSPITAL
Lead Author: Increase Ibukun Adeosun, M.B.B.S.
SUMMARY: Introduction: Prolonged psychiatric hospitalizetion has been associated with disproportionately higher cost
of health care, non-optimal use of scarce mental health
resources, psychosocial poverty, stigmatization and poorer
quality of life. Consequently, there is an increasing push for
shorter length of stay and community based mental health
services. There is scarcity of research on the factors associated with prolonged psychiatric hospitalization in subSaharan Africa. Such data is crucial for mental health
planning, resource management and related interventions
targeted at minimizing prolonged hospitalization. Objective:
To determine the correlates of length of hospital admission
among patients admitted to a psychiatric Hospital in Nigeria,
sub-Saharan Africa. Method: The clinical records of patients
(n=278) with psychiatric disorders hospitalized at the Federal
Neuro-Psychiatric Hospital Yaba Nigeria were reviewed. The
variables extracted included the socio-demographic characteristics, clinical diagnosis (according to the ICD-10 criteria),
frequency of review of the clinical management of the
patient, symptom profile and time to symptom resolution.
Data was analyzed using SPSS-IBM version 20. Results:The
mean length of hospitalization was 13 (± 6.7) weeks. Factors
associated with longer duration of hospitalization include
male gender (p=0.014), unemployment (p<0.001), single
marital status (p=0.014), schizophrenic illness (p=0.006),
lower frequency of clinical review (p<0.001) and worse
symptom profile (p<0.001). On linear regression analysis,
male gender (p=0.027), schizophrenic illness (p=0.007), lower
frequency of clinical review (p<0.001) and worse symptom
profile (p<0.001) predicted prolonged psychiatric admission.
Conclusion: A number of socio-demographic and clinical
factors may be foci of intervention targeted towards
minimizing prolonged psychiatric hospitalization. Development and use of clinical protocols may harmonize the
implementation of evidence-based service standards and
minimize the influence of socio-demographic status or other
biases on the length of psychiatric hospitalization.
P2-13
DETERMINANTS OF HOSPITALIZATION AMONG
ATTENDEES OF A PSYCHIATRIC EMERGENCY SERVICE IN
NIGERIA
Lead Author: Increase Ibukun Adeosun, M.B.B.S.
SUMMARY: Introduction: Psychiatric emergency services are
major gateways to in-patient mental health care. Several
unfavorable outcomes could result from either inappropriate
hospitalization or discharge of patients presenting to
psychiatric emergency services. Elucidating the factors
associated with the decision to hospitalize patients
presenting to emergency services could inform relevant
interventions in this regard. Objective: This study assessed
the factors associated with the decision to hospitalize
patients presenting to a psychiatric emergency department
in Nigeria. Method: The sample consisted of 648 attendees at
the Emergency Department of the Federal Neuro-Psychiatric
Hospital Yaba Lagos, Nigeria. The data obtained included
disposition (hospitalization versus non-hospitalization),
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AMERICAN PSYCHIATRIC ASSOCIATION
P2-15
LARGE SCALE DISASTERS WITH A HUMAN SCALE
RESPONSE: OUR EXPERIENCE OF PROVIDING RAPID
DISASTER RESPONSE WITH FOCUS ON RESILIENCE
Lead Author: Sander Koyfman
Co-Author(s): Rachelle Ramos, M.D., Grant Brenner, M.D.
SUMMARY: Finding the right match between providers and
needs, a story of Disaster Psychiatry Outreach work in the
Philippines in the aftermath of Typhoon Haiyan. Learning
Objectives: Common mental health recommendations in the
setting of a large scale disaster with focus on resilience Practical organizational aspects of coordinating a rapid
response to a vast disaster by preparing the most qualified
providers ahead of time and relying on years of experience of
similar responses to scale the response with safety and
practicality in mind. Background: CNN: "The monster
typhoon left behind a catastrophic scene after it made
landfall on six Philippine islands on November 8, 2013
leaving many without immediate access to food and medical
care. It flattened some communities and displaced about 3
million people." Disaster Psychiatry Outreach (DPO) is a
non-profit organization based in NYC. Our mission is to
alleviate suffering in the aftermath of disaster through the
expertise and good will of psychiatrists. To fulfill this
mission, DPO responds to catastrophes and provides
education and training in disaster mental health to a range of
professionals in the healthcare, public health and emergency
management sectors. We: - Organize volunteer psychiatrists
who provide immediate mental health services in the
aftermath of disasters in conjunction with government and
private charitable organizations; - Develop and implement
educational programs, training, and referral mechanisms,
and; - Develop research and policy in the field of disaster
mental health. DPO's activities are guided by its vision to
prevent the development of mental illness after disaster.
Most recently our volunteers, headed by Dr. Rachelle Ramos,
have responded to the Philippines in order to provide mental
health training and direct response in the aftermath of the
Typhoon Haiyan. Dr. Ramos was able to provide some of the
much needed education materials and direct services in
Tacloban and other hard hit locations. Our poster will
summarize what was done from the "ground zero" point to
"boots on the ground" and ultimately return to regular lives
and duties for the volunteers involved. How re-integration
and continuity even upon completion of a mission are key
components of resilience and accomplishment in the face of
wide scale trauma associated with disasters and disaster
response (such as participation in ongoing training and relief
organization work long after the acute response is over).
were categorized as depressive and AUDIT scores 8 or higher
were considered harmful or hazardous drinking. The results
were compared with age and gender matched participants
who were not in medical school. Of those surveyed, 8 males
(22%) and 8 females (32%) had BDI score of 14 or greater. 21
males (58.3%) and 15 females (60%) drank alcohol at least 24 times a month. 16% of both males and females had AUDIT
scores above 8, indicating harmful or hazardous drinking.
The individual subsets of the BDI and self-reported alcohol
consumption variables were analyzed to understand their
interrelationship.
P2-16
GLASS HALF EMPTY: DEPRESSION AND ALCOHOL USE IN
MEDICAL STUDENTS
Lead Author: Pallavi Joshi, M.A.
SUMMARY: High prevalence of depression and alcohol use
have been observed in physicians and medical students. It is
important to identify predictors of depressive symptoms and
alcohol use during their first two years of medical education,
a period during which behaviors and attitudes of physicians
develop. A survey using an anonymous self-administered
questionnaire was performed with 61 first and second year
medical student (36 male, 59 %) aged 21-30 years. The Beck
Depression Inventory-II (BDI-II) and Alcohol Use Disorders
Identification Test (AUDIT) were used to determine depresssive symptoms and alcohol use. BDI scores of 14 or higher
P2-19
WHEN YOU HIT ROCK BOTTOM, KETAMINE TO THE
RESCUE IN TREATMENT REFRACTORY DEPRESSION IN
ELDERLY POPULATION: A CASE REPORT
Lead Author: Munjerina Ahmed Munmun, M.D.
SUMMARY: Background: Depression is a multifactorial
illness, where trials of treatment have been implemented,
with hopes of establishing better quality of life. However,
many patients have tried multiple antidepressants, augmentation therapy and ECT to no avail. Ketamine is an
innovative drug, gaining popularity, for the rapid resolution
of symptoms in patients with refractory depression. Majority
of the studies published demonstrate the effectiveness of
ketamine in middle age demographics. There is a sparse
amount of data available for effectiveness of ketamine in
P2-17
WITHDRAWN
P2-18
SURVEY OF PSYCHOACTIVE SUBSTANCE USE AND
TREATMENT NEEDS OF STUDENTS IN A NIGERIAN
UNIVERSITY
Lead Author: Abidemi I Bello, M.B.B.S.
SUMMARY: Introduction: Use of psychoactive substances
among adolescents and young adults is a universal problem
associated with enormous health burden. Many studies have
determined the prevalence rates of psychoactive substances
among university students but there is paucity of data on the
degree of involvement in substance use and corresponding
treatment needs of the students, especially in Africa.
Objective: To assess the prevalence of substance use, severity
of drug use and the appropriate treatment needs of students
in a Nigerian university. Method: A cross-sectional survey of
the pattern of substance use among students (n=5938) of a
Nigerian university. The World Health Organization's
Alcohol, Smoking and Substance Involvement Screening
(ASSIST) questionnaire was used to collect data on lifetime
and 3-month prevalence of substance use. The substance
involvement scores of the questionnaire were used to derive
the levels of risk of substance use and the corresponding
treatment needs. Results: The participants had a mean age of
18.73(±2.35) years. The most commonly ever-used
substances were alcohol (32.5%), Tobacco (3.8%), Amphetamine or other stimulants (2.9%) and Opioids (2.5%); while
the commonly used substance in the past three months were
alcohol (11.4%), Opiods (1.4%) and Tobacco (1.1%). None of
the participants met criteria for high risk level of use, while
3.2% used at least one substance at moderate risk level.
Conclusions: At least 3% of students attending a tertiary
institution needed secondary intervention against substance
use. Those who were at moderate risk of multiple substances
might require more than brief intervention.
76
2014 INSTITUTE ON PSYCHIATRIC SERVICES
services were studied for gender, substances used, as well as
impact of those consults on treatment planning. Results:
After implementation of LCDC services in the PEC, several
trends were noted. The availability of LCDC services greatly
facilitated collaborative treatment planning during the
assigned shift when LCDC services were available. In
contrast, on weekends and other times, when no dedicated
LCDC services were available on site, the consults markedly
decreased combined with increased length of stay. Number
of LCDC consults increased by more than 40% since
inception of services. About half the patients concerned were
noted to be using more than one substance. The addition of
LCDC services allowed better transition to scheduling
patients into specialized addiction clinic at time of
discharge. Conclusions: implementation of specialized
LCDC services in the Psychiatric Emergency Center (PEC) is
a positive change that has allowed refinement of services
provided and a more comprehensive multidisciplinary
experience.
elderly population. Our case will demonstrate the safety and
efficacy of ketamine in geriatric population showing
resolution of symptoms in TRD for significant duration of
time. Case: 81 yr old Caucasian, married female with 40 years
history of relentless depression and multiple inpatient
admission, presented to crisis center for evaluation of
worsening symptoms of depression despite being on 3
distinct antidepressants. She exhibited anhedonia associated
with low energy, hopelessness, worthlessness, poor appetite,
increase sleep and apathy. Patient reported that her depresssion was successfully managed until May 2011. Her outpatient psychiatrist tried various different regiments but she
did not show clinical improvement. Since May 2011, she had
total of 4-inpatient psychiatric admission. She received 10
sessions of ECT in May 2011 without significant improvement. Despite the ECT treatment, patient was re- admitted
to inpatient unit the following month for the exacerbation of
depressive symptoms. Before admission, she was on
clonazepam 0.25mg BID, fluoxetine 20mg, nortriptyline
25mg HS, desvenlafaxine 150mg. The patient was started on
olanzapine 2.5 mg at bedtime. Her fluoxetine was up titrated
to 30mg oral daily. Patient was given ketamine 100 mg/ml,
injectable 45 mg at a rate of 70 ml/hr IV continuous over 45
minutes. After 1st day of infusion, depression improved by
brighter affect and mood, increased motivation, improved
energy and concentration. She was monitored one week
following infusion where she had shown significant clinical
improvement. Post transfusion, she did not demonstrate any
elevated blood pressure, dissociation, dizziness, blurry vision
although she had mild headache for short duration.
Discussion: Multiple studies demonstrated how ketamine
establishes rapid improvement of depressive symptoms after
receiving a single infusion. Majority of the research targets
middle age population, whereas this case showed the
effectiveness and safety of ketamine use in treatment refracttory depression in elderly. However, more studies would
need to be conducted to establish the long-term benefits. In
patients who failed to respond to conventional antidepressant treatment and ECT, the safety and efficacy of
ketamine in geriatric population showed resolution of
symptoms in treatment refractory depression paving the way
for future investigation.
P2-21
A PSYCHIATRIC EDUCATION PROGRAM IN CHILD &
ADOLESCENT MENTAL HEALTH FOR CHILD WELFARE
WORKERS
Lead Author: Joshua Russell, M.D.
Co-Author(s): Lauren Zohler, D.O.; Peter Martin, M.D.,
M.P.H.; David Kaye, M.D.; Sourav Sengupta, M.D.; Gail
Daniels; Vivian Figliotti; Robert Frank
SUMMARY: There is a severe shortage of child mental health
professionals, both in the medical field and in the community. Due to deinstitutionalization principles over the last 3040 years, mental health workers are being relied upon to
provide psycho-education to children and families as well as
communicate with psychiatrists. Often, mental health workers are on the front line in regards to diagnosing and
determining appropriate resources for children and their
families. To better serve the community, mental health
workers should have an understanding of the diagnostic
criteria, signs and symptoms, and treatment options for
common child and adolescent disorders. To date, there is
little in the way of standardized curricula on child and
adolescent psychiatry for mental health workers, particularly
those involved in social services. Given this situation, it is
imperative that work be done on developing a format that
can be generalized across different communities. A lecture
series was thus created with the goal of improving the
knowledge base for child and adolescent psychiatry. This
model utilized a partnership between two local educational
institutions (SUNY at Buffalo and Buffalo State College) and
a local Department of Social Services (Erie County). The
target audience was local Department of Social Services child
welfare workers. Objectives were created for the individual
lectures and series as a whole. Each lecture contained information on the diagnostic criteria of common disorders in
child and adolescent mental health, pharmacologic and nonpharmacologic treatments, and available referral resources
for children and families. A variety of teaching methods were
employed, including written cases, video cases, and
multiple-choice questions. Data were collected via surveys to
improve the quality of lecture material and further target
educational areas of need. Upon completion of the lecture
series, the materials used were placed on a statewide
database for workers who could not attend the live
presentations. Overall, preliminary data suggest that this
curriculum has improved the comfort level of mental health
P2-20
INTEGRATING LICENSED CHEMICAL DEPENDENCY
COUNSELING SERVICES INTO PSYCHIATRIC
EMERGENCY CENTER
Lead Author: Nidal Moukaddam, M.D., Ph.D.
Co-Author(s): Asim Shah, M.D.; Anu Matorin, M.D.; Aya
Aoshima-Kilroy, M.D.; Peter Muchmore, LCDC
SUMMARY: Background: a significant proportion of patients
presenting to the psychiatric emergency center have comorbid substance use disorders (SUD). The presence of an SUD
can complicate treatment of psychiatric disorders and lead
to exacerbation in several other areas, including a higher risk
of traumatic accidents and medical issues. However, there is
a dearth of information on formal program combining
substance se treatment with psychiatric treatments in the
emergency setting. This poster describes implementation of
specialized Licensed Chemical Dependency Counseling (
LCDC) services in the Psychiatric Emergency Center (PEC)
and trends noted in patients with SUD following the change.
Methods & Program Description: An LCDC was formally
employed to work full-time in the PEC setting (Monday
through Friday 8-5). Resulting consults requesting LCDC
77
AMERICAN PSYCHIATRIC ASSOCIATION
SUMMARY: Objective: Obesity and Diabetes Mellitus, II
(DM) are national epidemics. These related disorders are
responsible for increased morbidity, mortality, and healthcare costs. In the mentally ill, the prevalence of obesity is
twice that of the general population. Those with major
psychiatric disorders die 25 to 30 years earlier, on average,
often of illness associated with obesity. Research demonstrates that intervention for diabetes prevention and
associated co-morbidities can improve both healthcare
outcomes and cost. The hospitalized forensic inpatient has
multiple risk factors for obesity and DM including mental
illness, medication use, and inactivity. Recognizing this,
DSH-Atascadero, a California State Hospital with long-term
forensic inpatients, part of the California Department of
State Hospitals, researched and implemented a pilot program to prevent or delay DM in their hospitalized mentally ill
population. Methods: Hospital staff developed a curriculum
modeled after the Center for Disease Control's Diabetes
Prevention Program. This evidence-based, nationally recognized program was successful in preventing DM through
individualized lifestyle interventions. The pilot program used
group as opposed to individual treatment. The program used
a multidisciplinary team. Potential participants were
screened for risk for diabetes (Hemoglobin A1C ranging from
5.7 to 6.4%, a triglyceride/ high-density lipoprotein ratio
>3.5mg/dL or a waist circumference >40 inches), a projected
stay of 6 months or more, and a readiness to change their
physical activity and dietary intake. The pilot program
functioned over a 15 month period admitting new members
quarterly. The pilot started with 2 hours of education/
behavior groups and two hours of exercise groups per week.
Exercise groups were subsequently increased to three hours
plus optional evening hours. Hemoglobin A1C and weight
were followed. Results: A total of 57 patients participated in
the program. Results of the pilot show that 72% of patients
participating had lower Hemoglobin A1C after participation.
Additionally, 63% of patients registered in the pilot lost
weight. These outcomes are consistent with decreased risk of
DM. Conclusions: The high-risk population enrolled in this
pilot program increased glycemic control and decreased
weight during the pilot program. Improving health outcomes
through lifestyle interventions in the hospitalized seriously
mentally ill was possible. Given the risks of increased
morbidity, mortality, as well as increased lifetime healthcare
cost, providing evidence-based diabetes prevention
programs to the long-term hospitalized mentally ill should
be further analyzed. Important analyses would include costbenefit as well as Quality Adjusted Life Years added by these
interventions.
workers in dealing with the diagnosis and treatment of child
and adolescent mental health disorders (final results to be
reported). The principles behind the creation and implementtation of this curriculum can be applied to other
teaching interventions to improve the psychiatric knowledge
of community organizations.
P2-22
DEMENTIA STIGMA AND SERVICE AMONG CHINESE
AMERICAN IMMIGRANTS
Lead Author: Hei Tong Lam
Co-Author(s): Benjamin K.P. Woo, M.D.
SUMMARY: OBJECTIVE: Public awareness and research in
dementia have increased in recent years as the incidence of
various forms of dementia has increased due to population
aging. Recent studies have shown that ethnic minority
groups, including Chinese Americans, are consistently
underrepresented in utilization of dementia services. While a
lack of Chinese language resources contributes to poor
awareness of the disease, Chinese Americans must also face
a culture that places significant social stigma upon mental
illness. In this study, we sought to assess the level of
awareness of dementia services among Chinese Americans,
and its effect on the level of stigma towards the disease.
METHOD: Chinese American immigrants were recruited to
attend a dementia seminar in Los Angeles. A paper survey
questionnaires was administered in Chinese. One hundred
and fifty individuals who were fluent in Cantonese
participated in the study. The survey consisted of 15 true (T)
or false (F) statements regarding dementia awareness and
stigma towards the disease. Demographic variables
including sex, age, level of education, duration of time spent
in the United States, and family history of dementia were
self-reported. Descriptive analysis, t-tests and chi-square
analyses were conducted to identify participants who are or
are not aware of dementia services, and their stigma scores.
RESULTS: According to the survey, only 13% of the
participants felt aware of services for dementia patients in
their community, but 92% of the respondents indicated that
they would be interested in learning more. Our findings also
indicated that respondents who were aware of dementia
services score an average of 7.6 in stigma scores, while
respondents who were naive to the services score a 6.5 (p <
0.037). CONCLUSIONS: Chinese Americans who have
greater awareness of dementia services confer a higher level
of stigmatization towards the disease. These findings were
surprising, but there are many potential explanations.
People who are familiar with dementia services may have
sought these resources as a result of paranoia about
acquiring dementia themselves. Moreover, those who have
witnessed or participated in the stigmatization of dementia
first hand may be more inclined to seek information about
the disease. Nevertheless, our results reveal a pressing need
for greater dementia education in order to increase
awareness of dementia services, and to moderate the
stigmatization of the disease in the Asian American
community
P2-24
NMS AND ZIPRASIDONE
Lead Author: Muhammad Puri, M.D., M.P.H.
Co-Author(s): Rumana Rehmani, M.D.; Mehr Iqbal, M.D.;
Faisal Islam, M.D., M.B.A.
SUMMARY: An adverse reaction to an antipsychotic drug,
Ziprasidone (ziprasidone) in our case, can precipitate the
development of Neuroleptic Malignant Syndrome (NMS).
National Institute of Neurological Disorders and Stroke
(NINDS) defines NMS as a neurological disorder encompassing a myriad of untoward symptoms: (a) hyperpyrexia
(b) labile and/or elevated blood pressure (c) tachycardia (d)
diaphoresis (e) muscle rigidity as well as (f) a fluctuating
sensorium. Although, antipsychotic medications are generally regarded as the culprits in the development of NMS,
P2-23
DIABETES PREVENTION PILOT IN AN INPATIENT
FORENSIC MENTAL HEALTH HOSPITAL
Lead Author: Erin Dengate
Co-Author(s): Deborah Hewitt, Ph.D.; Ellen Beraud, R.D.;
Sarah Goible, R.T.; Tom Comar, F.N.P.; Sandra Thomas, R.N.;
Rebecca Kornbluh, M.D.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
is known about the nature of family involvement in the
context of first-episode psychosis (FEP); that is, what exactly
do families do for a loved one experiencing a FEP? This is a
significant knowledge gap with implications for clinical
practice, as families may support their ill loved one in a
number of different and important ways. Objectives: The
objectives of this preliminary study were (1) to investigate
the different ways in which families are involved in the lives
and treatment of youth experiencing a FEP as well as
satisfaction with and perceived helpfulness of this support,
comparing the perspectives of FEP patients and their
families; and (2) to explore the relationship between family
support for medication adherence and patients' objectively
rated medication adherence. Methods: The Family Involvement Questionnaire (FIQ), a novel measure created by senior
author S.I., was used to assess various aspects of family
involvement in the treatment and lives of youth with FEP.
FIQ data was collected for 23 FEP patients having received 6
months of treatment at a specialized early intervention
service in Montreal, Canada (the Prevention and Early
Intervention Program for Psychoses), as well as for 17 family
members of these patients. Results: Patients reported several
different types of family support, ranging from emotional/
psychological to financial/practical. Most patients strongly
agreed that their families were supportive (71.4%; n=15/21
respondents for this item) and agreed or strongly agreed that
they were involved in their treatment (78.2%; n=18/23). Both
patients and families appeared to be satisfied with the
current level of family involvement in patients' lives (66.6%
of patients, n=14/21; 76.4% of family members, n=13/17);
however, patients were more satisfied than families with the
current level of family involvement in their treatment (70%
of patients, n=14/20; 52.9% of family members, n=9/17).
Most patients and families perceived family involvement in
treatment as helpful or very helpful, but families endorsed
this to a greater extent (76.1% of patients, n=16/21; 93.7% of
family members, n=15/16). Finally, family beliefs about the
value of medication and their acceptance of non-adherence
were both found to be significantly correlated with patients'
medication adherence at Month 6 (r=0.58, p=0.01 and r=0.51, p=0.03, respectively). Conclusions: Families are
involved in the lives and treatment of youth with FEP in
several different ways, and the support they offer is seen as
helpful and largely satisfactory by both patients and families.
The FIQ is a promising measure of family involvement with
implications for clinical practice, as knowing exactly how
families support their ill loved one could shed light on
families' contributions to patients' recovery.
NINDS cautions that a sudden cessation of dopaminergic
drug use can also trigger NMS. As a psychiatric emergency,
improved outcome for NMS patients is contingent upon
early assessment and therapeutic intervention [8]. Neuroleptic Malignant Syndrome is more commonly associated
with typical neuroleptics, as opposed to the atypical
antipsychotic agents. However, the case presented below,
involves the rare presentation of a patient that developed
NMS subsequent to ziprasidone administration.
P2-25
SPIRIT, SOUL AND BODY VS. SUPEREGO, EGO, AND ID:
MORE SIMILAR THAN YOU THINK
Lead Author: Adekola Alao
SUMMARY: Introduction: Sigmund Freud was an unwavering atheist, and although his psychoanalytic theories and
models evolved over the course of his career, his irreverence
towards religious teachings and doctrines did not change.
Freud considered religion a collective neurosis, created in
reaction to human weakness and our infantile "longing for a
father. However, there are striking similarities between the
Freud structural model as well as the Christian' view of the
body, soul and spirit. We will describe the similarities in this
abstract. Freud's structural model -the id, ego, and
superego-were outlined in his publication The Ego and the
Id in 1923, and these concepts became the foundation for
many elements of modern psychoanalytic theory. The id
represents the drives and instincts of a person, which
established sexual impulses as crucial determinants of
personality. According to Christian belief, the human body
has a desire to sin. The body is also seen as a temporary
home until death. The ego is defined as the center of logic
and reason, orienting a person's internal state to the
surrounding reality. Comparatively, the soul is the center for
balancing the spirit and the body; it is an intangible force
that weighs both the physical and spiritual desires of life. The
superego is the moral compass accounting for guidelines
and prohibitions. The superego develops at ages 5 and up
when a child has the capacity to internalize abstract
principles and guidelines taught by parents and society. The
spirit is much like a moral compass, in that it is the
conscience of a Christian and determines right and wrong
according to the Bible. The spirit develops as one study the
Bible and communicates with God. The spirit is perfect and
does not want to sin. Much like the id, the desires of the flesh
are what cause the body to sin. Similar to the superego, the
spirit of a Christian provides the moral standard, and the ego
and the soul struggle between the spirit and the body.
Conclusion: Even though Freud was known as an Atheist, it
is interesting that Freud's topographical structural models
were similar to that of the Christian faith.
References:
P2-27
SUB-SYNDROMAL NMS SECONDARY TO ARIPRIPAZOLE
Lead Author: Philip P Paparone, M.D.
Co-Author(s): Adekola Alao M.D.
SUMMARY: Background Elevations in Creatine Kinase (CK)
above 1,000 (Units) are often found in patients with Neuroleptic Malignant Syndrome (NMS). This is a report of a
patient who complained of "muscle tightness" without any
other signs or symptoms of NMS except for elevated CK. We
speculate a sub-syndromal form of NMS. Methods A case of
a patient with a history of paranoid schizophrenia treated
with aripripazole and subsequently developed elevation in
CK will be discussed. Literature review for Neuroleptic
Malignant Syndrome, progression of NMS, elevated CK and
risk factors for NMS will be reviewed. Results Mr. D.R. is a 24year-old male with a past psychiatric history of Paranoid
Hothersall, D. 2004. "History of Psychology", 4th ed., Mcgraw-Hill: NY p.
290
Carter H. 2012. "The transformed Life", 5 Fold Media, LLP
P2-26
FAMILY INVOLVEMENT IN THE LIVES AND TREATMENT
OF YOUTH WITH FIRST-EPISODE PSYCHOSIS (FEP):
PERSPECTIVES OF FEP PATIENTS AND THEIR FAMILIES
Lead Author: Megan Pope, B.A.
Co-Author(s): Ashok Malla, M.D., FRCPC; Heleen Loohuis,
M.Sc.; Srividya Iyer, Ph.D.
SUMMARY: Background: A large body of research shows that
family involvement in the treatment of a loved one with
psychosis has a positive impact on outcomes, however little
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AMERICAN PSYCHIATRIC ASSOCIATION
illnesses (e.g., psychotic disorders; mood disorders; psychiatric illness secondary to other medical conditions; and
substance use disorders) in our PICU. We also sought to
investigate changes (before and after IBAP) in patient
avoidance and aggressive behaviors; patient engagement as
well as levels of patient boredom. Methods: Following
educational training sessions, PICU staff will implement a
modified IBAP protocol specifically designed for our PICU (a
six bed unit). This will involve implementation of both
sensory-based and recreation-based activities for patients to
be carried out on a daily schedule (one hour in duration).
These activities will be chosen in accordance with any
patient safety concerns. We will seek feedback regarding
both enablers and barriers to carrying out these activities
from patients and staff. Data will also be collected using the
following questionnaires: (1) Free Time Boredom Scale
(Ragheb & Merydith, 2001); (2) The Checklist of Unit
Behaviors (Hanson et al., 2013) and (3) Brøset Violence
Checklist (Clarke et al., 2010). Data will be collected using a
mixed design in which variables will be measured before and
after the rollout of IBAP and the impact of this intervention
will be measured in patients over time (upon admission,
prior to discharge and weekly measures in between). Results:
Preliminary analyses will be presented that will speak to both
feasibility and early behavioral changes observed following
the rollout of our IBAP. Conclusions: The implementation of
BA on a PICU is a novel and innovative concept. Given the
severity of psychiatric illness in such a setting, it requires
modification to allow for the essence of BA to be brought to
the patient in a manner that is both feasible and safe for the
patient population and the staff carrying out these activities.
We hypothesize that our IBAP will lead to enhanced patient
engagement and recovery, decreased boredom and aggression, and enhanced coping skills upon discharge.
Schizophrenia, Major Depressive Disorder currently in
remission and Alcohol Use Disorder. Patient presented to
the Emergency Department with an increase in psychotic
symptoms not controlled by his previous medication
regiment. Patient was started on aripiprazole 10mg PO daily
and in 2 days had complaints of rigidity and an increase in
CPK. The levels normalized after medication was discontinued. A re-challenge was considered but advised against.
Discussion The diagnosis of NMS is usually made as a result
of excluding structural brain disease via imaging, lumbar
puncture and EEG. Clinical diagnosis and confirmation of
diagnosis with lab tests like CK, CBC for leukocytosis and
LDH. Elevated CK in patients on atypical antipsychotics have
been shown to be a risk factor for patients in developing
NMS on future psychiatric admissions (1). Progression of
NMS has been studied and shown to follow a course
beginning with altered mental status and ending in
autonomic dysfunction (2). We speculate that this patient
was on the verge of developing NMS. Early stoppage of
aripripazole may have prevented the development of a full
blown NMS. Since NMS has a mortality rate of 11.6% (3),
identifying early signs and symptoms in conjunction with
appropriate laboratory tests such as like CK can help identify
NMS early and allow physicians to initiate treatment and
reduce mortality. Conclusion Adjunct laboratory tests in
patients on atypical antipsychotics can be important in
prevention of NMS and should accompany cases where
patients have a history of increased CK or complaints of
"muscle tightness" or rigidity.
References
1. Hermesh H, Manor I, Shiloh R, Aizenberg D, Benjamini Y, Munitz H,
Weizman A: High serum creatinine kinase level: possible risk factor for
neuroleptic malignant syndrome. J Clin Psychopharmacol.
2002;22(3):252.
2. Velamoor VR, Norman RM, Caroff SN, Mann SC, Sullivan KA, Antelo
RE: Progression of symptoms in neuroleptic malignant syndrome. J Nerv
Ment Dis. 1994;182(3):168.
3. Shalev A, Hermesh H, Munitz H: Mortality from neuroleptic malignant
syndrome. J Clin Psychiatry. 1989;50(1):18.
P2-29
KNOWLEDGE SEEKING AND DEPRESSIVE SYMPTOMATOLOGY: A RANDOMIZED INTERVENTION STUDY OF
THERAPEUTIC EDUCATION OF PATIENTS SUFFERING
FROM DEPRESSION
Lead Author: ADEL GABRIEL, D.P.M., M.Sc.
SUMMARY: BACKGROUND: Psycho-education may play a
significant role in improving depression treatment outcomes, and may lead to improved adherence to antidepressants. OBJECTIVES: The primary objective of the
study is to assess the efficacy of a systematic patientcentered psych-education program on the clinical outcomes,
and on knowledge seeking of depression in patients with
major depressive disorder. BACKGROUND: Psychoeducation may play a significant role in improving
depression treatment outcomes, and may lead to improved
knowledge seeking and to adherence to antidepressants.
OBJECTIVES: The primary objective of the study is to assess
the efficacy of a systematic patient-centered psycheducation program on the clinical outcomes, and on
knowledge seeking of depression in patients with major
depressive disorder. METHOD: 52 consenting patients with
confirmed diagnosis of major depression were randomly
assigned to a group (n = 32) who received systematized
psycho-education for depression, and to a waiting group (n =
20) who received standard care. The intervention group
received systematic education consisting of (1) Reading
material, "depression manual", (2) Individual or groups
educational sessions, emphasizing reflection, and feedback
through discussions facilitated by the research psychiatrist
P2-28
IMPLEMENTATION OF AN INNOVATIVE INPATIENT
BEHAVIOURAL ACTIVATION PROGRAM ON A
PSYCHIATRIC INTENSIVE CARE UNIT: PRELIMINARY
OUTCOMES AND FEASIBILITY
Lead Author: Marlene Taube-Schiff, Ph.D.
Co-Author(s): Jenna McLeod, R.T.; Krystyna Horak, R.N.;
Andrea Waddell, M.Ed., M.D., F.R.C.P.C.; Yasir Khan, M.D.,
F.R.C.P.C.; Sarah Flogen, R.N., M.Ed.; Anna Skorzewska,
M.D., F.R.C.P.C.
SUMMARY: Introduction: Patient engagement in the therapeutic milieu on an inpatient unit is an essential ingredient
to recovery and discharge. Behavioral Activation (BA) is a
structured, evidence-based intervention found to help
psychiatric patients modify avoidance behavior and engage
with their environment (Dimidjian et al, 2011). Recently,
Gollan and colleagues (2013) demonstrated that positive
affect is enhanced following BA interventions in a general
psychiatric inpatient ward. However, there is no published
research on the use of BA on a Psychiatric Intensive Care
Unit (PICU). Given that patients in this setting typically have
access to fewer activities and, potentially, increased levels of
boredom, modified BA interventions may lead to increased
patient engagement and, ultimately, recovery. Objectives:
We sought to investigate the feasibility of implementing an
innovative Inpatient Behavioral Activation Program (IBAP)
for patients experiencing a variety of severe psychiatric
80
2014 INSTITUTE ON PSYCHIATRIC SERVICES
and the patient was subsequently discharged to a long term
care facility. There are no approved pharmacological
treatments for FTD to date. Medications used in treatment of
other types of dementias are frequently used off label for
symptomatic treatment of FTD with varying levels of
success. Although the use of antipsychotics in dementia is
generally not recommended because of the evidence that
they increase mortality, they are frequently used in daily
practice when patients present with severe behavioral
problems, uncontrolled by other means. This is despite
evidence indicating that these populations of patients are
more sensitive to the potential side and adverse effects of
antipsychotics. We discuss the use of alternative options for
medication management of agitation and aggressive
behavior in this population.
(at least, 6 visits, 30 minutes each). The primary clinical
outcome measures included the clinician Rated Quick
Inventory of Depressive Symptomatology(QIDS-C) and the
self-rated Quick Inventory of Depressive Symptomatology(QIDS-SR. Patients in both groups completed (QIDSSR, and the Knowledge seeking behavior instrument (KSI), at
baseline, at 4, 8 and 12 weeks. The (QIDS-C) was rated
blindly by trained clinician RESULTS: At 12 weeks there was
significant (p< .01) reduction in the (QIDS-CR) and the
(QIDS-SR) scores in both the intervention and waiting group
patients. However, there were significant differences
between groups in (QIDS-SR, p< .001) and in (QIDS-CR, p<
.01) ratings over time, with the superiority for the
intervention group in reduction of depressive symptoms.
The number of hours spent in knowledge seeking as
measured by the (KSI), correlated negatively with the scores
of (QIDS-SR), and (QIDS-CR). CONCLUSION: Systematized
education may lead to significant reduction in clinical
symptomatology. However, it is less clear if such favorable
clinical outcomes including the significant reduction in
symptom severity are closely related to seeking knowledge of
depression.
P2-31
SIMPLE SCHIZOPHRENIA REMAINS A COMPLICATED
DIAGNOSIS: CASE REPORT AND LITERATURE REVIEW
Lead Author: Vishesh Agarwal, M.D.
Co-Author(s): Subani Maheshwari, M.D.; Vivek Agarwal,
M.B.B.S., M.R.C.Psych, M.MedSc.
SUMMARY: Background: Simple Schizophrenia was first
described by Otto Diem in 1903 and further elaborated by
Eugen Bleuler and Emil Kraepelin. It was included in the
International Classification of Diseases (ICD) in 1948 and
Diagnostic and Statistical Manual of Mental Disorders (DSM)
in 1952. It is characterized by oddities in conduct, inability to
meet societal demands and decline in total performance.
Limited published literature exists about the diagnosis and
management of simple schizophrenia. Case: 35 year old male
presented with depressive symptoms after having a head
injury on a public transport bus followed by complaints of
chronic pain and inability to return to work. He also reported
difficulty with memory and returning to school. He was born
to teenage parents and had significant neglect as a child. He
admitted to using marijuana during his teenage years.
During initial weeks of evaluation, lack of organization,
paranoia and need of assistance with instrumental activities
of daily living (IADLs) was observed. He added that these
symptoms worsened gradually over years and had existed
prior to injury. Psychological testing revealed intellectual
functioning in Low Average range with Full Scale Intelligence
Quotient (FSIQ) being 86, and similar results with all other
composite scores. He showed poor compliance to several
psychotropic regimens and continued to endorse depressive
symptoms. Clinical case worker provided assistance with
IADLs, while patient was seen in clinic for supportive
psychotherapy. Patient has shown minimal improvement
and continues to be disorganized and is unable to make
logical decisions. He is currently diagnosed with unspecified
depression and anxiety as we continue to debate the possible
diagnosis of simple schizophrenia. Psychological and
vocational testing initially done were inconclusive and are
being repeated. Conclusion: Schizophrenia can present with
a variable combination of positive and negative symptoms,
with some patients exhibiting mostly or only negative
symptoms. Because of this variability, it has been argued that
schizophrenia diagnosis should be on a dimensional rather
than categorical scale. It is essential to exclude alternative
diagnoses and have a complete work up including imaging
and psychological testing before reaching a final diagnosis.
P2-30
A CASE OF ADVANCED FRONTOTEMPORAL DEMENTIA
WITH RECURRING ATYPICAL NMS WHEN RECHALLENGED WITH ANTIPSYCHOTICS
Lead Author: Sonal Batra, M.D.
Co-Author(s): Samuel Oliver Sostre, M.D.; Rashi Aggarwal,
M.D.
SUMMARY: Frontotemporal degeneration is generally
responsible for most of the early-onset dementia cases,
affecting people aged 45-64. Depending on the predominant
symptoms, there are three variants of frontotemporal
dementia: the behavioral variant with progressive behavioral
changes, the semantic dementia with marked executive
impairment, and the non-fluent aphasia variant, characterized by profound language impairment. We present the
case of a 68 year-old Caucasian man with history of bipolar
disorder and frontotemporal dementia (FTD) diagnosed five
years earlier who was brought to the ED by his family for
worsening physical aggression and sexual disinhibition that
was unmanageable at their home. The patient was admitted
to the psychiatric unit after medical clearance. His home
medication regimen of risperidone 1 mg qAM and 1 mg qHS,
quetiapine 25 mg BID and 50 mg at HS, and divalproex
sodium 500 mg twice daily was adjusted by increasing the
total daily dose of quetiapine by 25 mg. The patient
subsequently developed an atypical form of neuroleptic
malignant syndrome characterized mainly by fever,
autonomic changes and altered mental status. He was
transferred to medicine where he received extensive medical
workup to determine the etiology of the fever and AMS
though none was found. The syndrome resolved after
discontinuation of his psychiatric medications. He was
transferred back to the psychiatry unit where he received one
dose of haloperidol 2.5 mg and quetiapine was restarted (at a
lower dose than before) for worsening behavioral aggression.
He subsequently re-developed an atypical NMS, similar to
previous syndrome, which resolved when antipsychotics
were once again discontinued. Divalproex sodium was
restarted with no return of signs/symptoms of atypical NMS
81
AMERICAN PSYCHIATRIC ASSOCIATION
SUMMARY: Objective: To investigate the depressive tendencies and self-care status of university students. Method:
A questionnaire survey was conducted on 926 second-year
students at our university who underwent a regular medical
checkup in 2013. The survey consisted of a depression and
anxiety scale (K10), WHO QOL-26 and a questionnaire on
measures related to stress and self-care. The present investigation analyzed data from 721 students. Result: Mean K10
score was 14.9. Score were higher than the cutoff of 25 in 49
students. Mean WHO QOL-26 score was 3.53. Students were
divided into groups by sex (302 males, 419 females). Mean
scores for social factor and environmental factor were higher
for males than for females. Three-hundred and thirty
students (50.2%) replied "Yes" to the question "Do you feel
stress in university life?", while 34 students (5.1%) replied
"Yes" to the question related to thoughts of suicide. The
proportion of students that had replied "Yes" to this question
was significantly higher for males than for females. Onehundred and thirty students (19.6%) replied "Yes" to the
question "Do you engage in measures to maintain your
mental health?" This "Yes" response was significantly more
common in females than in males. These students indicated
that the most common measures were, in descending order,
"Talking to a significant other or friend" (n=95, 73.1 %),
"Sleeping" (n=91, 70.0 %), "Listening to and playing music"
(n=84, 64.6%), "Eating something delicious" (n=81, 62.3%),
"Talking to family" (n=80, 61.5%), and "Participating in
exercise or sports" (n=64, 49.2%). Males were significantly
more likely than females to spend time engaged in sports or
exercise for mental health. Conclusion: The present findings
suggest that approximately 20% of students in this study took
measures to maintain mental health as part of their daily life
without on-campus support or support from medical
institutions. We hope to contribute to future health support
activities using these data.
P2-32
IMPLEMENTING GUIDELINES FOR METABOLIC
MONITORING OF PATIENTS ON ATYPICAL
ANTIPSYCHOTICS AND MOOD STABILIZERS
Lead Author: Saulo Castel, M.D., Ph.D.
SUMMARY: Background: The use of atypical antipsychotics
and mood stabilizers requires baseline physical and biochemical assessments and ongoing monitoring to optimize
patient safety. Adherence to the available guidelines to
inform clinical monitoring practices for patients on these
medications is poor. Objectives: (1) Identify barriers and
facilitators of adherence to guidelines for metabolic monitoring of patients on atypical antipsychotics or mood stabilizers; (2) design and implement interventions to improve
guideline adherence. Methods: (1) selection of guidelines for
metabolic monitoring by the International Society of Bipolar
Disorders consensus guidelines for the safety monitoring of
bipolar disorder treatments; (2) survey of 27 psychiatrists
regarding their attitudes and perceived practices; (3)
baseline audit of 135 charts of inpatients (35) and
outpatients (34 of an ACT team and 66 of a general
psychiatry clinic) under the care of these psychiatrists; (4)
focus groups with patients, psychiatrists and allied health
professionals to identify barriers and facilitators of guideline
implementation; (5) design and implementation of a multifaceted intervention to improve guideline uptake; (6) audit of
136 charts of inpatients and outpatients 3 months after the
implementation of the interventions to assess change of
practice. Charts were selected consecutively until target
number was reached. Setting: The department of psychiatry
of an Academic Health Sciences Centre, Toronto. Results: We
identified significant gaps between attitudes and perceived
practices and actual practices as assessed by the chart audit.
The focus groups informed of barriers (lack of resources,
gaps in knowledge and memory) and facilitators (mainly
attitude) towards guideline uptake. We designed and implemented a set of interventions: (1) provision of resources like
scales and blood pressure monitors; (2) checklists and
monitoring forms to remind and inform at the point of care;
(3) algorithms to manage abnormal results of monitoring
procedures; (4) an educational session with demonstration
of how to use the tools within a regular appointment
(simulation) . The post intervention chart audit identified
significant (p<0.001) improvements in the collection of
baseline data of medical history; smoking history, alcohol
use; drug use, cardio and cerebrovascular disorders, history
of diabetes, hypertension; baseline measures of dyslipidemia, blood pressure, weight and fasting blood sugar.
Although the improvement was significant with baseline
measures of weight and blood pressure increasing from 29 to
60% and 28 to 60% respectively, the overall uptake is still not
optimal as these measures were lacking in almost 40% of the
charts after the intervention. Conclusions: There were
important gaps between perceived and real practices. The
interventions were associated with an improvement in
practice. Limitations: We cannot establish a causal relationship as this was not a randomized trial.
P2-34
A CASE OF SUICIDALITY ASSOCIATED WITH THE ANTIEPILEPTIC DRUG PRIMIDONE USAGE FOR 4 DAYS
Lead Author: Ashwini Gulwadi, M.D.
Co-Author(s): Pankaj Lamba, M.D.; Kalappurackal C Joseph,
M.D.
SUMMARY: Introduction: Primidone (Mysoline) is an
antiepileptic drug (AED), which has been around since 1950,
is used in the control of seizures and essential tremors. In
2008, US FDA issued a warning on AEDs highlighting the
increased risk of suicidality. This was based on a metaanalysis of 199 randomized clinical trials of eleven AEDs
which reported suicide-related events to be twice that of
placebo, although it did not include primidone. A subsequent study which looked at risk of suicidal acts associated
with fifteen individual anticonvulsant, demonstrated a low
risk of suicidal acts with primidone compared to other AEDs.
Here, we want to present a case report describing a patient
who attempted suicide within four-days of starting primidone for mild tremor. We believe this case report is
important given that earlier studies included patient with
epilepsy or psychiatric disorders which are independent risk
factors for suicide and these studies did not describe the
individual patient events. Case description: A 79-year-old
male with no previously diagnosed psychiatric and substance abuse problem was admitted after committing a
serious suicide attempt. He reported feeling increasingly
irritable and frustrated two days after being started on
primidone for tremor by primary care physician. He added
P2-33
DEPRESSIVE TENDENCIES, QOL AND THE SELF-CARE
ENVIRONMENT OF JAPANESE UNIVERSITY STUDENTS
Lead Author: Mika Tanaka, M.D.
Co-Author(s): Sachiyo Aratake; Yuki Mase; Nobuhiko
Watanabe; Yuji Tanaka M.D. PhD.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
P2-36
VISUAL HALLUCINATIONS FOLLOWING STROKE: A CASE
REPORT ON CHARLES BONNET SYNDROME
Lead Author: Sumi Treesa Cyriac, M.D.
Co-Author(s): Leyla Baran Akce, M.D., Anil Jain, M.D.
SUMMARY: Introduction: Disorders of perception comprise
some of the most important and complex phenomena
encountered in psychiatric assessment. Perceptual disturbances, particularly hallucinations, are usually but not
always characteristic of psychiatric disorders such as
schizophrenia and delirium. Charles Bonnet Syndrome
(CBS) is a disorder characterized by complex visual hallucinations with insight, not accompanied by psychotic
symptoms, usually observed in elderly patients with an
acquired impairment of vision. We report a case of CBS with
symptoms in the hemianopic field following an occipital
infarct. Case report: This is an 84 year old male who
presented to ER with complaints of visual hallucinations. His
medical history was significant with a recent stroke,
pacemaker due to atrial fibrillation, hypertension, coronary
artery disease, hyperlipidemia, and mild dementia. He was
admitted to medical floor 2 weeks prior to this recent
admission after a stroke. Neurological examination then was
significant for visual field defect on the right side, right
hemiparesis and right hemianopsia. Left upper and the
lower extremities were normal. Right lower extremity
showed mild weakness and up going plantar reflex.
Neurological findings were suggestive of left occipital lobe
infarct. CT head was within normal limits. Unfortunately
MRI of the brain was not obtained since the patient had a
pacemaker. Psychiatry was consulted for evaluation of Complex Visual Hallucinations (CVH). He reported for the1 week,
he has been seeing people who are 7-8 feet in height and tiny
people running around the house, moving around, sticking
their heads out of the curtain, seeing old cars flying in front
of him off and on. It occurs predominantly early in the
morning and sometimes later in the evening. He never had
this kind of visual problem previously. He does not act on it.
The figures do not talk to him. Sometimes he puts his hand
just to make sure that it is not real, although in his mind, he
knows it is not real. He reported that he knows that it does
not exist. He did not report auditory hallucinations, delusions, or any other psychotic symptoms. He was diagnosed
with CBS, following occipital lobe infarct. We recommended
Aripiprazole 2 mg at bed time. Discussion: CVH has been
associated with organic brain disease, and are a common
referral reason to psychiatrists in consultation liaison. Our
case is consistent with CBS. Multiple neurologic disturbances can be associated with new onset visual
hallucinations in the elderly. The consultation liaison
Psychiatrist can assist with work up of possible etiologies,
thereby preventing the mismanagement of elderly patients
presenting with visual hallucinations.
that "earlier that day, I snapped and took about 30 pills
starting with "p" (later confirmed as primidone). As nothing
happened, I cut my wrist twice with a knife and waited,
hoping to die." However, his brother found him approximately half-an-hour later and alerted EMS. In ED, labs were
unremarkable except UDS was positive for barbiturates. The
laceration on wrist was found be deep and 7 cm in length
and needed suturing. He was remorseful about his attempt
and denied suicidal ideation. On further psychiatric evaluation, he did not endorse or demonstrate a full psychiatric
syndrome. Though, he did report some mild sadness after
separation from wife almost 20 years back and was otherwise
socially active and functioning well. Primidone was discontinued on admission and during the hospitalization he
continued to feel non-suicidal and showed a broad affect. He
was discharged with the diagnosis of Depressive Disorder
NOS. Discussion: This case illustrates the violent and
aggressive nature of the suicidal event in otherwise mentally
and physically healthy person within short interval of
starting primidone for essential tremor.
References:
Patorno E1, Bohn RL, Wahl PM, Avorn J, Patrick AR, Liu J, Schneeweiss S:
Anticonvulsant medications and the risk of suicide, attempted suicide, or
violent death; JAMA. 2010 Apr 14;303(14):1401-9.
VanCott AC1, Cramer JA, Copeland LA, Zeber JE, Steinman MA, Dersh JJ,
Glickman ME, Mortensen EM, Amuan ME, Pugh MJ: Suicide-related
behaviors in older patients with new anti-epileptic drug use: data from
the VA hospital system; BMC Med. 2010 Jan 11;8:4.
P2-35
DEPRESSIVE SYMPTOMS AND SUICIDAL IDEAS AMONG
THE ELDERLY LIVING ALONE IN KOREA
Lead Author: JeeHoon Sohn, M.D., Ph.D.
Co-Author(s): Maeng Je Cho, M.D. Ph.D.; Ji Eun Park, M.D.; Ji
Min Ryu M.D.; Seung Hui Ahn, M.Sw.
SUMMARY: Background: The suicide rate of Korea is one of
the highest among the developed countries, and particularly,
suicides among the older adult are very prevalent in Korea.
We examined the depressive symptoms and suicidal ideas
among the elderly living alone in the urban center of Seoul,
Korea. Methods: Subjects of the survey were senior citizens
aged 65 years or older, living alone in the community. They
were selected randomly from one district level community in
Seoul. We interviewed the subjects in the community with
Korean version of the Mini International Neuropsychiatric
interviews, Korean version of the Mini Mental Status Exam,
and the WHO quality of life scale. Results: A total of 408
seniors completed the interview. Majority of subjects were
females (71.1%). Mean age was 76.5 years. Almost all of them
had no occupation and very low monthly income. Subjects
had very limited social network and activities. Current
depressive disorder was found in 22.1% of subjects with
54.9% showing some signs of cognitive decline. During last
year, 9.8% of subjects had serious suicidal ideas, with 1.8%
actually attempted suicide. Life-time suicidal idea was found
in 25.9% with 8.6% have experience of suicidal attempt. The
predicting factors of higher suicide risk in the elderly living
alone were total isolation from the social network, current
and past history of depressive disorder, and low quality of
life. Conclusion: Depressive symptoms and suicidal ideas are
very prevalent in the elderly living alone in the community.
To alleviate this, both formal and informal social support
need to be strengthened and depressive symptoms should
be screened regularly.
P2-37
KETAMINE:KING OF LUB DRUG AND ANESTHETIC
PROVIDES A BREAKTHROUGH AS IT SHOWS EFFECTIVENESS IN TREATMENT RESISTANT DEPRESSION (TRD): A
CASE REPORT
Lead Author: Abhishek Rai, M.D.
Co-Author(s): Will Van Derveer; Fadi E. Georges
SUMMARY: INTRODUCTION: Ketamine is used as an
induction and maintenance of general anesthesia. Ketamine
a non-competitive antagonist at NMDA receptor is a potent
antidepressant with effect within hours. We report the first
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AMERICAN PSYCHIATRIC ASSOCIATION
Racial/ethnic disparities in physical health care in the U.S.
have also been well described. Methods: In 2009, the Washtenaw Community Support and Treatment Services (CSTS)
embedded a disease management program (composed of
nurse care managers and peer support specialists) and a
primary care nurse practitioner into its behavioral health
sites. The interventions delivered were directed at improving
the health and wellness of consumers with ambulatory care
sensitive conditions (asthma, chronic obstructive pulmonary
disease [COPD], diabetes, cardiovascular disease, hypertension) and co-morbidity clusters, as well as certain premorbid parameters that lead to disease. Outcome measures
included not only proxy measures of physical health status
(i.e., BMI, blood pressure, triglycerides, hemoglobin A1C),
but also consumers' perspective of their physical wellbeing
and number/types of interventions by staff. Results: Results
were analyzed using logistic regression at intervals 1, 2, 3, 4
and 5 years after consumer entry into the disease management program. Consumers in the disease management
program were more likely to maintain or show a decrease in
BMI, systolic blood pressure, and diastolic blood pressure
than CSTS consumers not receiving disease management
services. Consumers in the disease management program
were less likely to endorse improvement or maintenance of
physical health status than were CSTS consumers not
receiving disease management services. African-American
consumers achieved or exceeded results achieved by Caucasian consumers for certain parameters. Conclusions: Taken
together this data suggests that disease management and
reverse co-location of primary care providers can result in
maintenance or improvement in physical health parameters
for consumers with SPMI or ID and co-occurring substance
use disorders across gender and race. Increased awareness of
health issues due to education may have resulted in
enhanced cognizance of physical health status.
case of use of intranasal ketamine for the patient of
Treatment resistant depression. CASE REPORT: Mr. X is a 55
Years old Caucasian male, presented with symptoms of
anxiety, insomnia, and depressed mood which had gradually
increased over decade and worsened over 2003. After
evaluation he was diagnosed with Treatment resistant
depression, anxiety disorder with co-morbid substance
abuse. Medical diagnosis of OSA, hypogonadism, and
hypothyroidism. Patient had failed trial of multiple antidepressants and psycho-therapy for more than a decade.
Before treatment with ketamine patient was on disability and
very depressed with retrospective (BDI) score of 26. Looking
into antidepressant failure ketamine treatment was discussed and decision made to start intranasal ketamine.
Patient was given 150mg/mL IN Ketamine (via metered dose
pump). Starting dose of 15mg/ 0.1 mL IN q 3 days (Nov 2013)
titrated to 30mg/.2 mL qod ( Jan 2014). Titration was based
on clinical improvement and side effects monitoring. First
several doses were self-administered in the physician's
office, with patient having a ride home from the dose
administration and not drive for 3 hours. As the dose was
titrated his BDI score decreased to 13 (reflected 50 %
reduction). Noticeable side effects were dissociative symptoms including some out-of-body sensations "not knowing
who I was" for a few minutes after his doses, mild headache
and dizziness. Side effects were noticeable after 2nd and 3rd
dose. Side effects stabilized with further doses of ketamine
and patient was followed up every week. Patient currently is
stable on 30mg/.2ml IN qod with no current side effects
except for mild nasal irritation. Discussion: The basis of
rapid action of ketamine is noncompetitive antagonism of
NMDA receptor (1), synaptogenesis (AMPA) and increase in
neurotropic factor (BDNF). Ketamine was challenged due to
its short half-life lack of oral preparation and potential for
abuse. Ketamine rapid onset of therapeutic efficacy and
potential to reduce risk of suicide and improvement in sleep
makes it an attractive treatment option. CONCLUSION:
Significant (50%) improvement in symptoms of depression
over 8 weeks period when he failed 10 years of aggressive
antidepressant and therapy treatment. Improvement in
sleep and addiction problem. No withdrawal symptoms
despite occasional missed dosages of IN ketamine.
Important unanswered question: How long to treat? / Is
tapering and discontinuing needed?
Reference:
P2-39
PREVALENCE OF MENTAL ILLNESS AND ADDICTION IN
MEDICALLY COMPLEX PATIENTS
Lead Author: Jennifer M Hensel, M.D., M.Sc.
SUMMARY: Background: Researchers and policy makers are
increasingly interested in characterizing and intervening
with the highest users of healthcare because they account for
a disproportionate amount of healthcare spending. Mental
illness and addiction are associated with high rates of medical co-morbidity and health service utilization. However, the
burden of mental illness and addiction among high cost
users of complex medical services has not been quantified.
Aim: To quantify the prevalence of mental illness and
addiction across incremental cost groups for users of
complex medical services under universal healthcare in
Ontario, Canada. Methods: We used population-level sociodemographic and health administrative data available for all
Ontarians 18 or older between April 1, 2011 and March 31,
2012 to calculate total individual health care costs associated
with use of any of the following complex medical services for
any non-mental health related reason: inpatient hospitalization, emergency department, cancer clinics, dialysis
clinics, home care, complex continuing care or rehabilitation. Individuals were then ranked from lowest to highest
according to their cost. We identified individuals with
schizophrenia, major mood disorders (bipolar disorder or
major depressive disorder) and substance use disorders
based on diagnoses recorded in the health services databases
in the 2 years preceding the observation period. We com-
1. Zarate et al; A Randomized Trial of an N-methyl-D-aspartate
Antagonist in Treatment-Resistant Major Depression; Arch Gen
Psychiatry. 2006; 63(8):856-864
P2-38
DISEASE MANAGEMENT: COHORT EFFECTS ON
PHYSICAL HEALTH OUTCOMES IN A COMMUNITY
MENTAL HEALTH SETTING
Lead Author: Karen K. Milner, M.D.
Co-Author(s): Trish Cortes; Jessica Sahutoglu; Mike Harding;
Brandie Hagaman; Tim Florence; Jeremy Yu
SUMMARY: Background: Population health is an approach
to health that aims to improve the health of an entire
population. A principal priority to achieving this overarching goal is to reduce health disparities related to social,
environmental, cultural and physical health factors among
different population groups. It is well documented that the
population of individuals with severe and persistent mental
illness (SPMI), intellectual disabilities (ID), and co-occurring
substance abuse/SPMI or ID, is at high risk for physical
morbidity and mortality due to preventable medical illness.
84
2014 INSTITUTE ON PSYCHIATRIC SERVICES
acid. 6 (20%) of the women had a physician typed notation
that some discussion of pregnancy risks took place. For
example: "Discussed teratogenic effects of lithium with
patient. Declined birth control due to not being sexually
active." 4 (14%) women had a generic risk statement:
"Discussed medication and risks associated with pregnancy.
Conclusion: Even in academic medical centers work needs to
be done to increase counseling in regards to teratogenic risks
associated with psychiatric medications. Future work is
needed to develop and refine the education tools to meet the
needs of the community.
pared the prevalence of each of these disorders among the
top 10% and 1% of individuals ranked by cost of non-mental
health medical service use, to the lowest decile group;
generating crude odds ratios (OR) and 95% Confidence
Intervals (CI). Results: From a total of 10,909,351 insured
Ontarians during the observation period, 3,150,100 (28.9%)
utilized complex medical services. The mean annual costs
for the top 1% and top 10% of users ranked by cost were
$122,391 and $36,001 respectively, compared to $118 for the
bottom 10% of users. Compared to the bottom decile of
users, the top 10% of users had a higher prevalence of
schizophrenia (1.4% vs. 0.9%, OR: 1.55, 95% CI 1.48 to 1.62),
major mood disorders (8.3% vs. 5.9%, OR 1.45, 95% CI 1.43 to
1.48) and substance use disorders (5.4% vs. 4.4%; OR 1.25,
95% CI 1.22 to 1.28). Compared to the bottom decile of users,
the top 1% of users had higher prevalence of schizophrenia
(2.0% vs. 0.93%; OR 2.19, 95% CI 2.01 to 2.39), major mood
disorders (10.4% vs. 5.9%; OR 1.88, 95% CI 1.79 to 1.93) and
substance use disorders (7.0% vs. 4.4%; OR 1.64, 95% CI 1.57
to 1.72). Conclusions: The highest costing 10%, and
particularly 1%, of users of complex medical services in
Ontario have significantly higher rates of psychiatric comorbidity than low cost users. This supports a need for
attention to mental health in the design and delivery of
service in complex medical care settings, with potential
implications for healthcare costs.
1. NIMH.NIH.GOV. The Numbers Count: Mental Disorders in America.
[cited 2014 March]; Available from: http://www.nimh.nih.gov/health/
publications/the-numbers-count-mental-disorders-in-america/
index.shtml.
2. Nguyen HT, Sharma V, McIntyre RS. Teratogenesis associated with
antibipolar agents. Advances in therapy. 2009;26(3):281-94.
3. Coffey K, Shorten A. The challenge of preconception counseling: Using
reproductive life planning in primary care. Journal of the American
Association of Nurse Practitioners. 2013.
4. Magalhaes PV, Kapczinski F, Kauer-Sant'Anna M. Use of contraceptive
methods among women treated for bipolar disorder. Archives of
Women's Mental Health. 2009;12(3):183-5.
P2-41
SUBSTANCE ABUSE AMONG PHYSICIANS
Lead Author: Milapkumar Patel, M.D.
Co-Author(s): Anjan Bhattacharyya, M.D.; Alan Felthous,
M.D.
SUMMARY: Physician substance abuse is a significant
societal problem that affects all aspects of medical care.
Similar to general population, there is a 10-15% prevalence
of physicians with substance abuse. Physicians today have
strived hard to achieve excellence in training yet, surrounded
by the pressures of higher standards of clinical competence.
Factors in their personal lives may place them at risk to drug
abuse and mental disorders. Even residents in training were
reported to have a history of using substances. Physicians
who abuse alcohol and drugs will do whatever they can to
avoid detection. Denial on part of the abuser and hiding at
great lengths is indicated to be the hallmark of substance
abuse. It is said that peer monitoring and reporting is an
ethical responsibility. However, many physicians do not
report their colleagues. In addition to stigma, physician
leaders and administrators are reported to have little training
on handling situations in dealing with an impaired
colleague. The Missouri State Medical Association, recognizing the need for assisting the impaired physicians,
established the Missouri Physicians Health Program (MPHP)
in 1985. The study was conducted from 1995-2002 at MPHP
to help impaired physicians. The recovery rate of this study
of 197 participants was 90%. The average number of referrals
was 24 per year from 1995-2002. Physician impairment is a
real and significant public health concern. It is clear that
there are defined risk factors, including psychosocial history,
family history and certain medical specialties are more likely
to have substance use issues than others. As physicians, it is
imperative for us to have a moral and professional obligation
to preserve society's trust by monitoring self and helping
impaired colleagues. Society expects and deserves competent and safe health care providers. Competent care is
expected from everyone as well as protection of patients.
P2-40
REDUCING THE RISKS ASSOCIATED WITH PSYCHIATRIC
TERATOGENIC MEDICATIONS
Lead Author: Lynneice Bowen, M.D., M.Ed.
Co-Author(s): Leslie Nwoke, M.D., M.P.H.; Glenda L. Wrenn,
M.D., M.S.H.P.
SUMMARY: Background: Bipolar disorder is a chronic illness
affecting 5.7 million American adults, typically presenting in
young adults (1). In the United States 49% of pregnancy is
unplanned. Unplanned pregnancy is particularly problematic among those with bipolar disorder because the
psychiatric medications used as first line treatment are
teratogenic. Lithium, Carbamazepine and Valproate are FDA
category D due to the risk of fetal malformations and
neurobehavioral toxicity including reduced IQ (2). The FDA
recommends that women of child bearing age be counseled
on the potential risks associated with these medications.
Despite these recommendations, previous studies have
shown that preconception counseling is not taking place
with women taking teratogenic medications (3) and women
with bipolar disorder are not taking recommended contraceptive precautions (4). In this study, we explored the rate of
preconception counseling and use of risk reduction
strategies at an urban academic medical center. Purpose: To
assess the rate at which women of childbearing age with
bipolar disorder served at Grady Behavioral Health are being
counseled in regards to teratogenic risks of psychiatric
medications. Methods: Systematic chart review of women
age 18-45 treated with target medications from Sept 2013 to
January 2014. Deidentified data was gathered using an Excel
based chart abstraction form. Results: Of 28 eligible cases,
with regards to contraceptive usage 4 women were
permanently sterilized and 2 used condoms. None of the
women had prescriptions for oral contraceptives or folic
85
AMERICAN PSYCHIATRIC ASSOCIATION
unfamiliar to civilians. Few resources are available to
educate civilian providers about this unique population.
Most peer-reviewed articles on military-related mental
health issues involve veterans rather than SMs. Outside of
the media, military, and federal agency reports, little
evidence-based data exists on the prevalence of psychiatric
disorders in SMs, and few efforts have been made to
reconcile differences between cultures of civilian and
military psychiatric care. Methods: Investigators collected
demographic and clinical variables from the medical records
of 121 psychiatric inpatients, over a one and a half year
period from 2012 to 2013. These patients were served in a
community hospital psychiatric unit that specialized in SM
treatment. These SM data were compared to publicly
available statistics for Veterans Administration (VA) inpatient
admissions from 1996-2001 and VA records of mental health
diagnoses during 2001-2005. SMs in this study and in the VA
reports all served in Operations Iraqi Freedom (OIF) and
Enduring Freedom (OEF). Results: Fifty-three percent of SMs
were diagnosed with posttraumatic stress disorder (PTSD),
with older SMs more frequently affected. Over 50% of SMs
had three or more disorders (median = 3.5). Sixty-four
percent of SMs had depressive disorders, 16% had anxiety
disorders, and 70% had substance use disorders. A history of
childhood abuse was reported by 35% of SMs; of those, 76%
reported physical abuse and 38% reported sexual abuse.
Prevalence of depression among VA admissions was
estimated at 12%, substance use at 9.5%, and anxiety
disorders at a rate of 6%. Among veterans, roughly 13% had
PTSD, with younger patients most affected. The median
number of diagnoses was three, with 27% having more than
three disorders. Forty percent of the veterans endorsed
childhood abuse (22% physical and 18% sexual abuse).
Conclusions: Compared to VA data, SMs in this study had a
higher rate of PTSD, depression, anxiety, and substance use
disorders. Older SMs were at higher risk for illness. The
overall incidence of reported childhood abuse was lower
among SMs, but the percentages of physical and sexual
abuse were higher. Psychiatric illness was the leading cause
of hospitalization for SMs. This population was clearly
different from veterans, and faced unique treatment
challenges such as limited access to particular medications,
addiction potential of commonly prescribed medications,
and side effects that may impair performance while on duty.
Future research and information focusing on the needs of
SMs receiving treatment in civilian psychiatric facilities is
greatly needed.
P2-42
ADAPTING THE LOOK-AHEAD STUDY INTERVENTION
FOR PERSONS WITH DIABETES AND PSYCHOTIC
ILLNESS: METHODOLOGY AND PRELIMINARY RESULTS
Lead Author: Rohan Ganguli, M.D.
Co-Author(s): Sabrina Hassan; Todd Jenkins; Margaret Hahn;
Gary Remington; Paul Gorczynski; Kinnon MacKinnon; Hiren
Patel; Mehreen Bhamani; Kevin Acuna
SUMMARY: Background: Diabetes is prevalent at 2-3 times
the general population rate in individuals with psychotic
illnesses and the rates of diabetic co-morbidities are also
higher in this population. Obesity accounts for a large
proportion of the increased risk of diabetes, heart disease
and premature mortality in this population. The most
effective behavioral intervention for persons with diabetes
was in the Look-AHEAD study, but those with serious mental
illness were excluded. Thus we decided to adapt the LookAhed intervention and offer it to individuals with psychotic
illness and co-occuring Type-2 diabetes mellitus. We report
below the results from the first 20 subjects who completed
the first 6months of the study. Methods: The year-long
publicly available Look-AHEAD intervention was first
modified to make it appropriate to the circumstances of
community-dwelling seriously mental ill individuals. We
then commenced a randomized controlled clinical trial with
individuals who had a psychotic illness and co-morbid
diabetes. The individuals were randomized to either the
Modified Look-AHEAD Intervention or to usual care, in a
ratio of 2:1. The intervention group subjects attended weekly
sessions for 6 months and then sessions every other week for
the next 6 months. The main pre-specified outcome was
changein weight from baseline to the end of the study.
Results: Of the 20 completers, 13 were in the intervention
and 7 in the control group. Mean change in weight (baseline
weight minus 6 month weight) was -4.37 Kg in the
intervention and -0.37 Kg in the controls, with a trend level
of significance for the difference (p=0.088). There was one
outlier in each of the groups, hence a non-parametric
analysis of the weight change was also performed (MannWhitney test) which was statistically significant (p=.03). We
also performed a t test with outliers removed from both
groups and the difference between groups was statistically
significant (p=.005; t=3.293; df=16). Of the patients who lost
weight, only one was in the control group. Conversely, of the
patients who gained weight over the 6 months, only one was
in the intervention group. Conclusions: The adapted LookAHEAD intervention is feasible to implement with persons
who have diabetes and serious mental illnesses like
psychotic disorders. Our preliminary results also show that
the majority of those participating in the intervention get
some benefit in the form of weight loss. Since the
intervention was provided by clinicians, it is likely that it
could be implemented in most setting where communitydwelling patients are treated.
P2-44
METHYLPHENIDATE HYDROCHLORIDE EXTENDED RELEASE CAPSULES IN A RANDOMIZED DOUBLE-BLIND
STUDY OF CHILDREN AND ADOLESCENTS WITH ADHD
Lead Author: Sharon B. Wigal, Ph.D.
Co-Author(s): Akwete L. Adjei, Ph.D., Ann Childress, M.D.,
Wei-wei Chang, Ph.D., Robert J. Kupper, Ph.D.
SUMMARY: Introduction: Although a broad range of
pharmacological treatments for symptoms of AttentionDeficit/Hyperactivity Disorder (ADHD) exists, Methylphenidate hydrochloride extended release capsules, with its novel
drug release profile, once- a-day dosing, and multiplicity of
strengths offers a novel alternative for the management of
ADHD. Hypothesis: Methylphenidate hydrochloride extended release's ratio of immediate/extended release (IR/ER)
content (37%/63%) is unique among the available controlled
release methylphenidate products and may produce a
P2-43
STILL IN UNIFORM: MENTAL HEALTH DISORDERS
AMONG ACTIVE MILITARY SERVICE MEMBERS
COMPARED TO VETERANS
Lead Author: Gwen A. Levitt, D.O.
Co-Author(s): Felicitas Koster, D.O., James Palmer, D.O.,
Jennifer Weller, Ph.D. SUMMARY: Background: Active duty
military service member (SMs) admissions to community
psychiatric hospi-tals are increasingly common, bringing
challenges and military-related requirements that are
86
2014 INSTITUTE ON PSYCHIATRIC SERVICES
administrative files for the Janssen® Connect® (JC)
program, we identified patients whose HCP determined a
Janssen LAI to be the most clinically appropriate treatment
option and for whom an alternate injection site was
requested. Patients were classified as adherent if their
estimated proportion of days covered was ≥ 80%. Logistic
regressions evaluated the associations between adherence,
and patient characteristics, and request for offerings such as
alternate sites of care. Results: Among 6,589 patients with
completed enrollment information receiving care from HCPs
at 740 inpatient/outpatient facilities, 38.8% of the enrollment
forms included an alternate injection site of care. While
gender and age distributions did not vary by request for
alternate injection site of care, patients for whom this
offering was requested were more likely enrolled from an
inpatient setting and more likely new to treatment than
patients who did not request the offering. Of those for whom
alternate site of care HCP-ordered injections were requested,
55.8% received ≥ one injection. In a subgroup of patients for
whom alternate sites of care were requested and whose
HCPs ordered paliperidone palmitate(n=1,100), 9% were in
the program for ≤ 3 months and were less likely than those in
the program for ≥ 4 months to achieve ≥ 80% proportion of
days covered (55.0% versus 81.3%, p-value<0.0001).
Conclusions: This administrative data analysis of the JC
program support suggests that alternate injection sites of
care may help patient's follow their HCP's orders, but
additional assistance may be needed for those transitioning
from inpatient settings and those at high risk for nonadherence. A summative evaluation of this program support
is on-going.
clinically meaningful rapid initial (morning) post-dose effect
with a subsequent more prolonged effect across the day.
Methods: A parallel, randomized, double-blind, fixed-dose,
placebo-controlled study was conducted at 16 centers to
evaluate the safety and efficacy of methylphenidate hydrochloride extended release (10, 15, 20, 40 mg/day) in the
treatment of ADHD in patients aged 6 to 18 years. There were
4 study phases: 1) 4-week screening/baseline; 2) 1-week,
double-blind treatment; 3) 11-week, open-label, doseoptimization period; and 4) 30-day follow-up call. The
primary endpoint was change from baseline to the end of
phase 2 in ADHD Rating Scale-Fourth Version (ADHD-RSIV); secondary endpoints included the Clinical Global
Impression Scale–Improvement (CGI-I), adverse events
(AEs), and quality of life measures. Differences between
treatment groups were analyzed by ANCOVA including
terms for treatment, investigational site, and baseline
ADHD-RS-IV total score as a covariate for the intent-to-treat
population. Results: Children (N=280; mean age 10.8 ± 3.0
years) diagnosed with ADHD (by DSM-IV-TR criteria) were
screened, 230 entered the double-blind phase and were
administered either 1 of the 4 strengths of methylphenidate
hydrochloride extended release or placebo (~45 in each
treatment group). Two hundred twenty-one (221) completed
the 1-week double-blind phase. Methylphenidate hydrochloride extended release resulted in significantly greater
improvement versus placebo in mean ADHD-RS-IV score
change (p < 0.05) and CGI-Improvement (p < 0.05). Clinical
significance was seen at each of the four fixed doses used in
the study. Two hundred (200) subjects completed the
subsequent 11-week open label phase, during which their
Methylphenidate hydrochloride extended release dose was
optimized. There was continuing improvement in efficacy
over time. Quality of life measures did not statistically
improve during the double-blind period but showed
significant improvements by study end. The most common
AEs were consistent with known AEs for the
methylphenidate drug class. Most treatment-emergent AEs
were mild or moderate in severity, and there were no serious
drug-related AEs throughout the study. Conclusions: Oncedaily methylphenidate hydrochloride extended release was
significantly more effective than placebo in treating symptoms of ADHD in children 6-18 years. The novel drug release
profile mainly due to methylphenidate hydrochloride
extend-ed release's unique immediate/extended drug
release ratio and up to eight dose strengths provide more
options for customized treatment of ADHD.
P2-46
MATERNAL WARMTH AND DEVELOPMENT OF PSYCHIATRIC DISORDERS: A LONGITUDINAL STUDY AMONG
PUERTO RICAN CHILDREN
Lead Author: Olga Santesteban, M.S.
Co-Author(s): Hector R. Bird, MD, Glorisa Canino, PhD;
Cristiane S. Duarte, PhD, MPH
SUMMARY: OBJECTIVE: To examine the prospective association between maternal warmth and psychiatric disorders in
Puerto Rican children over the course of three years.
BACKGROUND: According to the parental acceptancerejection theory (PARTeory, Rohner, 1991), children who
perceive rejection have poor psychological adjustment
presenting more emotional and behavioral problems like
depression, delinquency, violence and conduct disorders.
The impact of maternal warmth among Puerto Rican
children is expected to be strong, given the importance of
family relationships for this ethnic group. METHODS:
Sample: This is a secondary analysis of the Boricua Youth
Study which assessed yearly (3 times) Puerto Rican children
aged 5-13 in two different sites: San Juan (Puerto Rico) and
the South Bronx (NY), N=2,491 (Bird et al., 2007). Only
subjects who participated in waves 1 and 3 were included in
this analysis (n=2161). Main Measures: a) Maternal warmth
and acceptance (Parent report) is a 13-item measure
(answered on a 4-point Likert-type scale) adapted from the
"Hudson's Index of Parental Attitudes" (Hudson, 1982); b)
Child Psychiatric Disorders (Parent report): Parent version of
the Diagnostic Interview Schedule for Children-IV (DISC-IV)
(Shaffer et al. 2000) was used to asses children's disorders; c)
Demographic factors: Child gender; child age; family
income; d) Other parental factors: psychopathology; Data
Analysis: Logistic regression analysis was carried out relating
P2-45
ALTERNATE INJECTION SITES OF CARE FOR PATIENTS
WITH SCHIZOPHRENIA: ACCESS AND CONTINUED USE
OF LONG-ACTING INJECTABLE ATYPICAL ANTIPSYCHOTICS
Lead Author: Kate L. Lapane, M.S., Ph.D.
Co-Author(s): Carmela Benson, M.S., John Fastenau, M.P.H
SUMMARY: Background: For individuals with schizophrenia,
adherence to antipsychotic medication is sub-optimal. Nonadherence increases the risk of relapse and hospitalization.
The extent to which providing alternate injection sites of care
for long-acting injectable (LAI) improves use of LAI in
accordance with health care professional (HCP) orders
remains unknown. Objective: To compare characteristics
and patient outcomes of enrollees with schizophrenia who
requested the alternate injection sites offering versus those
who did not request the offering. Methods: Using the 2-year
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AMERICAN PSYCHIATRIC ASSOCIATION
satisfaction. Attachment-related avoidance was a stronger
predictor of relationship satisfaction than attachmentrelated anxiety. Discussion: The results indicated that high
levels of anxiety and high levels of avoidance are associated
with low levels of relationship satisfaction. Previous research
found that high levels of anxiety and avoidance are
associated with attachment insecurity, while low levels of
anxiety and avoidance are associated with attachment
security. Conclusion: it is possible to conclude that securely
attached lesbians are likely to report more satisfaction
compared to insecurely attached lesbians. The results are
consistent with previous research conducted with
heterosexual married couples, which highlights similarities
between heterosexual and lesbians individuals and couples.
the likelihood of the disorder (depression, anxiety, Disruptive Behavior Disorder or ADHD,) to maternal warmth across
waves adjusting for potential confounders as demographics,
other child psychiatric disorders and parental psychopathology. RESULTS: There were no significant differences
in rates of psychiatric disorders along the 3 waves or by site
(with the exception of DBD in w3). We calculated adjusted
(AOR) and 95% confidence intervals (95%CI) for the relation
between maternal warmth at wave 1 and the presence of
child disorder (Depression, Anxiety, Disruptive Behavior
Disorders (DBD) or ADHD) at wave 3. There were statistically
significant prospective associations between high levels of
maternal warmth and decreased likelihood of having
depression (AOR=0.22; 95%CI=0.09-0.53, p<.001), anxiety
(AOR=0.43; 95%CI=0.22-0.82, p<.05), DBD (AOR=0.18;
95%CI=0.10-0.32,
p<.000)
and
ADHD
(AOR=0.40;
95%CI=0.23-0.68, p<.001), adjusting for demographic, other
parental and child factors. CONCLUSIONS: Maternal
warmth is a protective parental factor against psychological
disorders in Puerto Rican children. These results are
consonant with PARTheory, which supports the relevance of
maternal warmth for Puerto Rican children. Implications for
interventions are discussed.
P2-48
EARLY RESULTS OF HEALTHCARE UTILIZATION OUTCOMES IN PATIENTS DIAGNOSED WITH SCHIZOPHRENIA PARTICIPATING IN REACH OUT STUDY
Lead Author: Carmela J. Benson, M.S.
Co-Author(s): Carmela J. Benson, MS, David Biondi, DO, John
M. Fastenau, RPh, MPH, Paul L. Juneau, MS Jessica Lopatto,
PharmD, Xue Song, PhD
SUMMARY: Objective: To evaluate inpatient admission and
emergency room (ER) visits during the first six-months of
study participation among patients with schizophrenia
treated with paliperidone palmitate long-acting injection
(PP) or oral atypical antipsychotic therapy (OAT). Methods:
Data were obtained from the Research and Evaluation of
Antipsychotic Treatment in Community Behavioral Health
Organizations, Outcomes (REACH OUT) study, an ongoing,
naturalistic, observational study of adult patients receiving
atypical antipsychotic treatment in community behavioral
health organizations for either schizophrenia or bipolar I
disorder. For this analysis, patients with schizophrenia
receiving either PP or OAT were included. To account for the
selection bias, propensity matching was performed
estimating the likelihood of receiving PP treatment accounting for covariates such as age, gender, insurance type,
comorbidities, and baseline healthcare resource utilization
(6-months prior to study enrollment). Utilization measures
evaluated were inpatient admission and ER visits during the
first 6-months. Descriptive statistics and relative reductions
in utilization measures from baseline were compared
between the matched PP and OAT treated patients. Within
PP treated patients, we examined the proportion of new or
continuing users of PP and their healthcare utilization at
months 6. Results: Out of the 412 analyzable patients treated
with PP and 264 treated with OAT, 190 PP were matched 1:1
to 190 OAT. Post-matching, the two cohorts were comparable based on age (41.2 vs. 40.9, P=0.816), gender distribution
(68.9% vs. 65.3% male, P=0.431), ≥1 baseline inpatient
admission (29.5% vs. 33.2%, P=0.413), or ≥1 baseline
emergency room visits (34.7% vs. 38.4%, P=0.430). In the 6months follow-up period, PP patients had a nominally
greater reduction in healthcare utilization from baseline
compared to OAT patients in both ER visits (47.2% vs. 33.2%)
and inpatient admissions (50.0% vs. 44.2%). Within the PP
cohort, 41% are new to PP and 59% are continuous users of
PP and a lower percentage of new PP users had inpatient (6%
vs 10%) or ER admission at 6-months (8% vs 14%).
Conclusions: Among a matched cohort of patients diagnosed
with schizophrenia, this analysis at 6 months demonstrated
a reduction in healthcare utilization associated with paliperidone palmitate long-acting injectable vs oral atypical anti-
P2-47
ADULT ATTACHMENT STYLES AND RELATIONSHIP
SATISFACTION AMONG LESBIANS
Lead Author: Sonarzu Gullu-McPhee, Psy.D.
Co-Author(s): Lawrie A. Ignacio, Psy.D., Nancy Morgan,
Ph.D., Micheal M. Omizo, Ph.D.
SUMMARY: Introduction: This study was designed to explore
the relationship between attachment styles and relationship
satisfaction among lesbians. In the last few decades, most
research conducted with heterosexual samples highlighted
the role of attachment styles and relationship satisfaction
and quality. Individuals who were securely attached reported
higher relationship satisfaction compared with individuals
who had an anxious or avoidant attachment style. Due to the
paucity of research with lesbians, this study was conducted
to explore the nature and direction of the relationship
between attachment styles and relationship satisfaction
among lesbians. The purpose was to evaluate the predictive
power of attachment-related anxiety and attachment-related
avoidance and to identify the variable with the strongest
association to relationship satisfaction. Hypothesis: The
hypothesis guiding the study was that attachment-related
anxiety and attachment-related avoidance would vary in
strength and direction in terms of its ability to predict
relationship satisfaction among lesbians. Method: Through a
snowball method of data collection, 303 lesbians from the
United States, Europe and other international locations
participated by responding to invitations sent via emails and
postings on social networking sites, and completing an
online survey that included a demographic questionnaire,
the Relationship Assessment Scale (RAS; Hendrick, 1988) and
the Experiences in Close Relationships-Revised instrument
(ECR-R; Fraley, Waller, & Brennan, 2000). Relationship
satisfaction was the dependent variable, while attachmentrelated anxiety and attachment-related avoidance were
independent variables. Results: Multiple regression analysis
was conducted to examine the hypothesized relationship.
The results supported the hypothesis. There was a significant
negative relationship between attachment-related anxiety
and relationship satisfaction and a negative relationship
between attachment-related avoidance and relationship
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
directly affect glycolysis. More than one hundred patients
have been described with prominent clinical symptoms
characterized by muscle cramps, exercise intolerance,
Rhabdomyolysis and myoglobinuria often associated with
hyperuricemia and hemolytic anemia. It is to our knowledge
after intensive literature review that only one case report was
published about a patient with Glycogen storage disease
presenting initially with psychiatric symptoms including
Visual hallucinations. We present a case diagnosed with
Tarui disease, presenting to the emergency room with
paranoid delusions and disorganized thought process. Case
Narrative We present the case of 27 y.o. male with history of
schizophrenia, admitted to the hospital due to auditory
hallucinations and paranoid delusions. Reviewing the
patient's records revealed Past psychiatric diagnoses of
schizophrenia. Medical history was significant for Tarui
disease. On reviewing his laboratory results, the total CK
level was >32000 and hyperuricemia at the time of
admission. Collateral information obtained from mother:
Mother reported that patient at age 8 started to have
difficulty in school, and was diagnosed with learning
disability after decline in grades. Patient also had muscle
cramps and was found to have hematuria and after
exhausting diagnostic work up in Columbia University, he
was diagnosed with Tarui disease at age 12. Since then,
patient was receiving Magnesium infusion and liver and
kidney functions were monitored biweekly. Three years
prior to this presentation, patient was observed by family to
have paranoid delusions, auditory hallucinations and
agitation which resulted in multiple psychiatric hospitalizations and he was misdiagnosed with paranoid schizophrenia On this admission due to the high creatinine
phosphokinase level, starting patient on antipsychotic was a
challenge. As patient had prior good response to Olanzapine,
it was started again Medical, Urology and Gastroenterology
teams were consulted. Intravenous fluids were started.
Initially patient continued to be paranoid and irritable. With
medical management the CPK level decreased to 1463. The
mental status improved with clearing of auditory
hallucinations. Patient continued to be paranoid and
guarded, yet with no obvious agitation. Discussion This case
report brings to attention the possible atypical presentation
of Glycogen storage Disease with psychiatric symptoms.
Avoiding misdiagnosis with psychiatric disorder would
ensure better management and prognosis.
psychotics. Further evaluation of this treatment comparison
over a longer term is warranted.
P2-49
MODE OF DELIVERY: EFFECTS ON MATERNAL AND
NEONATAL ATTACHMENT BEHAVIOR IN THE SECOND
DAY OF LIFE
Lead Author: Lourdes R. Garcia Murillo, M.D.
Co-Author(s): Valeria Costarelli, M.D., Joana Fernandez, M.S.,
Ana Malalana-Martinez, M.D., Miguel A. Marin-Gabriel,
M.D., Ph.D., Isabel Millan, Ph.D., Ibone Olza-Fernandez,
M.D., Ph.D.
SUMMARY: INTRODUCTION: Babies born with a number
of systems of instinctive behavior. These behaviors, such as
the neonatal primitive reflexes, form the pre-attachment
system during the first 8 months of life. OBJECTIVE: Study
how type of delivery can influence in the attachment
behavior of the newborn and the mother, during an
experimental situation of stress in the second day of life.
METHODS: 127 mothers and their newborns were included:
45 vaginal deliveries after oxytocin administration (VaO), 41
vaginal deliveries without oxytocin (VaWO), and 42
programmed c-section (C-S). In the first 48 hours of life, we
put the baby in biological nurturing position. It was filmed
for 15 minutes, introducing in the 12 min a brief separation
of 5 seconds. These videos were analyzed by a blind
observer, who collected the neonatal primitive reflexes.
These were: hand to mouth, finger flex/extend, mouth gape,
tongue dart, arm cycle, leg cycle, foot/hand flex, head lift,
head right, head bob/nod, Babinsky, suck, plantar grasp,
swallow, jaw jerk. RESULTS: Mean gestational age was 39.2
(SD=1.2) weeks in the VaO group, 39.6 (SD=1.2) weeks in the
VaWO and 38.9 (SD=0.9) weeks in the in the C-S (p=0.007). In
the VaO group 46.7% were girls, 48.8% in the VaWO group
and 45.2% in the C-S. Mean weight of the newborns was 3240
(SD=476) grams in the VaO group, 3323 (SD=375) in the
VaWO and 3322 (SD=354) in the C-S. In the analysis of the
neonatal primitive reflexes it was found that the mean in the
VaWO group was 74.1% (SD=25.4) of the reflexes; in the VaO
group the mean was 58.4% (SD=28.9) and in the C-S group
was 63.6 (SD=26.7). Comparing between groups, we found a
statistically significant difference between the group of
VaWO and the VaO groups, not between the other groups.
CONCLUSIONS: Newborns who were delivered with oxytocin administration presented less percentage of neonatal
primitive reflexes. Further studies of the implications of this
finding are required.
REFERENCE:
P2-51
LITHIUM USE FOR THE TREATMENT OF PSYCHOTROPICINDUCED HYPONATREMIA
Lead Author: Farha B. Motiwala, M.D.
Co-Author(s): Dr. Amel Badr, MSc, MD
SUMMARY: Objective: Lithium use for the treatment of
psychotropic induced hyponatremia. Background: Atypical
antipsychotics are known to cause Syndrome of inappropriate Antidiuretic hormone and accordingly hyponatremia.
This has been a challenge in treating psychotic patients
especially patients with psychogenic polydipsia as part of its
symptoms. Lithium is known to induce nephrogenic
insipidus and could be helpful to resolve antipsychotic
induced hyponatremia. Case Narrative: Patient is a 40 yr old
male with a history of schizoaffective d/o bipolar type.
Patient has been treated with valproic acid and fluphenazine. Patient had multiple presentations to emergency room
due to altered mental status and agitation which was found
to be induced by hyponatremia. Patient also had psycho-
Olza Fernández I, Marin Gabriel MA, Garcia-Murillo L, Malalana
Martinez A, Costarelli V, Millan Santos I. Mode of delivery may influence
neonatal responsiveness to maternal separation. Early Human
Development, Volume 89, Issue 5, May 2013, Pages 339-342, ISSN 03783782, 10.1016/j.earlhumdev.2012.11.005
P2-50
THE DIAGNOSTIC CHALLENGE OF PSYCHIATRIC
SYMPTOMS IN GLYCOGEN STORAGE DISEASE
Lead Author: Farha B. Motiwala, M.D.
Co-Author(s): Dr. Amel Badr, MSc, M.D.
SUMMARY: Objective We present this case report with the
aim to bring to attention the Rare yet possible atypical
presentation of Glycogen Storage Disease with psychiatric
symptoms. Misdiagnosis of the patients with psychiatric
disorder may result in delayed and inappropriate treatment
Rational and Background: Tarui Disease [Phosphofructokinase deficiency} was the first disorder recognized to
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AMERICAN PSYCHIATRIC ASSOCIATION
medical wards and to improve behavioral code algorithms.
References:
genic polydipsia. Diagnosis of hyponatremia due to SIADH
was made as biochemical blood and urine test results were
consistent with SIADH. Medical causes of SIADH were ruled
out and it was concluded that hyponatremia was due to
psychotropic medications and psychogenic polydipsia.
Patient was started on lithium and clozapine. Repeated
blood tests showed gradual correction of sodium level,
without any sodium supplements given to patient.
Discussion: The patient had low level of lithium and low
levels of sodium at the time of admission which suggests that
lithium did not cause hyponatremia. Patient was started on
lithium which was one of patient's home medications.
Patient was able to maintain normal sodium levels with
lithium. Thus lithium is useful for the treatment of hyponatremia induced by psychogenic polydipsia or psychotropic
medications. Conclusion: Lithium induces nephrogenic
diabetes insipidus and thus counteracts effects of ADH.
Lithium can be effective for patient s with schizoaffective
disorder as it can treat both psychiatric symptoms and
prevent hyponatremia. Further research is required to
explore the role of lithium in treatment of hyponatremia.
1. Hodgson M. et al., 2012, Managing Disruptive Patients in Health Care:
Necessary Solutions to a Difficult Problem
2. Flannery R. B et al, 2006, Elderly Patients Assaults: Empirical Data from
the Assaultive Staff Action Program with Risk Management Implications
for EMS Personnel
3. Grenyer BF et al., 2004, Safer at work: development and evaluation of
an aggression and violence minimization program.
4. Forster JA et al., 2005, kNOw workplace violence: developing programs
for managing the risk of aggression in the health care setting
5. Lepping P et al., 2013, Percentage prevalence of patient and visitor
violence against staff in high-risk UK medical wards.
P2-53
33 YEAR OLD MALE WITH AGGRESSIVE BEHAVIOR AND
HOSTILITY DURING TREATMENT WITH LEVETIRACETAM
WITH SEIZURE DISORDER
Lead Author: Muhammad Puri, M.D. Co-Authors: Deepti
Mughal, M.D., Kalliopi-Stamatina Nissirios, M.S.
SUMMARY: We report a case of a 33 year old AfricanAmerican male who presented in our Emergency Department after an altercation with his mother. The patient's
mother insisted on admitting the patient in our psychiatric
unit, as she was very concerned because the patient had
endorsed homicidal thoughts the past week. From a review
of the patient's medical records a history of a seizure
disorder since 1998 is noted, as well a history of intellectual
disabilities since birth, and a a traumatic brain injury at 2
year of age. The patient's mother feels overwhelmed and she
reports that changes in the patient's behavior have been
apparent for nearly a year, which corresponds with the time
the patient was started on Levetiracetam treatment by his
neurologist, for management of his seizure disorder The
purpose of this case report is to establish a side effect of new
onset or worsening aggression and hostility while on
treatment with Levetiracetam for seizure disorder.
P2-52
THE MANAGEMENT OF DISRUPTIVE AND POTENTIALLY
VIOLENT PATIENTS ON INPATIENT MEDICAL UNITS
Lead Author: Simona Goschin, M.D.
Co-Author(s): Clifford Gimenez MD, David Edgcomb MD,
Nancy Maruyama MD
SUMMARY: Introduction: The management of disruptive
patients on medical floors can be very challenging especially
since the staff is not trained to manage this type of situation.
A fast and organized approach is needed and a clear algorithm for intervention is essential. Our hospital has developed a behavioral "code" for the non-psychiatric floors
called a STAR code (Safety Team Assessment Response). We
describe the STAR code procedure and report data on these
patients. Methods: We performed a retrospective review of
the STAR code consults from January 2013 to December 2013
for demographics, psychiatric and medical diagnoses.
Results: Thirty-two patients required STAR codes. Twentythree were male and nine female. There were two predominant age groups: 40-50 year-olds (n=9) and >70 year-olds
(n=9). The psychiatric diagnoses included psychotic disorders (n=11), neurocognitive disorders (n=10), substance
use disorders (n=8), delirium (n=5), mood disorders (n=5)
and personality disorders (n=4). Most patients had cardiovascular disease (n=21) and a quarter had comorbid diabetes
mellitus (n=9). Discussion: We present an algorithm
developed in our hospital for intervention in emergent
situations when patients threaten or become violent on
medical units. We describe the training and composition of
the team and the role of the consultation liaison (CL)
psychiatrist. Our data suggests that STAR code patients are
predominantly male with a bimodal age distribution
(middle-aged and elderly). Psychotic, cognitive disorders
and cardiovascular disease are common. Further research is
needed to identify risk factors for disruptive behavior on
P2-54
A 30-YEAR OLD FEMALE WITH MOYAMOYA DISEASE
WITH ASSOCIATED DEPRESSION
Lead Author: Muhammad Puri, M.D.
Co-Authors: Deepti Mughal, MD, Kalliopi-Stamatina
Nissirios, MS
SUMMARY: We report a case of a 30 year old Caucasian
female who was admitted voluntarily in our hospital with a
chief complain of depression and status post suicidal
thoughts with onset of two weeks. From a review of the
patient's medical records a history of Moyamoya Disease
since 2002 has been noted. Moyamoya Disease is a rare
progressive syndrome of cerebral occlusions and transient
ischemic attacks. The patient reported that her disease has
been managed with two neurosurgeries and with appropriate medication. The patient was admitted to our clinic for
management and treatment of her depressive symptoms.
The purpose of this case report is to establish a causative
relationship between Moyamoya disease and depression and
to discuss the importance of further research on the
neuropsychological sequelae of MMD.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
modalities to increase information processing efficiency.
These findings suggest a hypothesis that specific changes in
selective attention and interhemispheric interactions during
hypnosis could be reflected in left-right information transfer
calculated from bilateral electrodermal measurement (EDA).
In the present study we have performed EDA measurement
in 35 psychiatric outpatients during congruent and incongruent Stroop task. The results show that significant
correlation between hypnotizability measured by Stanford
scale SHSS:C and pointwise transinformation (PTI) during
congruent Stroop task in the period after hypnotic suggestion inducing black-white seeing (r=-0.43, p<0.01) has been
found. In summary, the results indicate that attentionally
demanding conditions during hypnosis distinguish patients
with higher hypnotizability.
POSTER SESSION 3
P3-1
CLOCK DRAWING TEST AND THE MMSE ASSESSMENT, A
CLINICAL CORRELATION WITH TREATMENT RESPONSE
IN A PATIENT WITH ACUTE PSYCHOSIS
Lead Author: Bashkim Kadriu, M.D.
Co-Author(s): Mohamed Eldefrawi M.D., Vicente Liz M.D.
SUMMARY: Background: We present a case report data of a
46 y/o HIV seropositive male presented with paranoid delusions and impaired cognitive symptoms for more than one
week. This including changes in attention, disruption in the
sleep wake cycle, confabulation and threats toward staff in
the unit. In addition, the patient presented with significant
left hemineglect in the clock-drawing test (CDT), and inability to tolerate the administration of the mini-mental state
exam (MMSE), but unremarkable laboratory profile.
Methods: We used CDT, as cognitive screening instrument is
used in wide range of neuropsychiatric illnesses. For CDT we
utilized Sunderland scoring system due to its high reliability
and correlation with the MMSE (Solomon et al 1998).
Results: Interestingly the initial CDT was significant for left
side lateralization/hemineglect, which was scored as 2/10,
but unable to tolerate a MMSE (0/30). Numerous test
performed ruled-out delirium, patient further subjected to
CDT and MMSE in timely manner (every 5 days), which
showed time-dependent improvements with each administration, which intriguingly was correlated with the
antipsychotic treatment response. Discussion: Studies have
shown that the direction and the magnitude of hemineglect
in psychotic patient could be correlated with medication
treatment response (Bracha et al, 1987). Our case study
shows that in acute psychosis there is high degree of visualspacial and executive function impairment, partly explained
by the hyperdopaminergic state (Carter et al., 1996), which in
some instances might present with lateralization or neglect.
Interestingly, the magnitude of clock drawing impairment
closely correlated with clinical symptomatology. Conclusions: In an attempt to shed light on the undergoing
pathology of our patient, one should not underscore the
importance of the quick assessment tests such CDT in not
only eliciting undergoing pathology but also as indirect
measures of antipsychotic treatment response. The team is
well aware that this could be an isolated case and more data
are needed to validate the use of CDT on the initial
assessment and treatment response in psychotic patient.
References:
P3-3
STRESS, DISSOCIATION AND ELECTRODERMAL
COMPLEXITY
Lead Author: Petr Bob, Ph.D.
Co-Author(s): Miroslav Svetlak, PhD, Charles University
SUMMARY: Recent findings indicate that neural mechanisms of consciousness are related to integration of
distributed neural assemblies. Recent findings suggest that
dissociation could be described as a level of neural disintergration reflecting a number of independent processes by
means of neural complexity. In the present study measurement of dissociation, traumatic stress symptoms and neural
complexity calculated using nonlinear analysis of electrodermal activity (EDA) [during rest and Stroop task] were
performed in 70 heatlhy participants (mean age 29.6).
Significant relationship between EDA complexity measured
by pointwise correlation dimension and dissociative symptoms during rest on the right side has been found (Spearman
R=0.43, p<0.01). These results indicate that electrodermal
complexity may reflect a level of dissociative symptoms and
represent predictive factor of stress response and possibly
for PTSD.
P3-4
PALIPERIDONE PALMITATE LONG-ACTING INJECTABLE
DELAYS RELAPSE TO MOOD AND PSYCHOTIC
SYMPTOMS IN PATIENTS WITH SCHIZOAFFECTIVE
DISORDER
Lead Author: Dong Jing Fu, M.D., Ph.D.
Co-Author(s): Ibrahim Turkoz; R. Bruce Simonson;David
Walling;Nina Schooler; Jean-Pierre Lindenmayer; Larry Alphs
SUMMARY: Introduction: Symptoms of schizoaffective disorder (SCA) are complex and disabling, with higher risks of
hospitalization, suicidality, and substance abuse than in
schizophrenia. Although efficacy of antipsychotics in SCA
has been reported, few large controlled studies have examined relapse prevention with antipsychotic medication.
Results of the first controlled maintenance study of the longacting injectable antipsychotic, paliperidone palmitate (PP),
in SCA are presented. Method: This randomized, doubleblind, placebo (PBO)-controlled, international study
(NCT01193153) included subjects who met Structured
Clinical Interview for DSM-IV Disorders (SCID)-confirmed
DSM-IV diagnosis of SCA experiencing an acute exacerbation of psychotic symptoms with prominent mood symptoms ((≥16 on YMRS and/or HAM-D-21). Subjects could
continue adjunctive stable doses of antidepressants (AD) or
mood stabilizers (MS). After stabilization with PP (78-234 mg
[50-150 mg equivalents of paliperidone]) during a 13-week,
Carter et al 1996. Perceptual and attentional asymmetries in
schizophrenia: further evidence for a left hemisphere deficit. Psychiatry
Res. 1996 May 17;62 (2):111-9.
Solomon et al. 1998. A seven-minute neurocognitive screening battery
highly sensitive to Alzheimer's disease. Archives of Neurology. 55:349355.
Zama et al, 2008: The Value of the Clock Drawing Test with Case
Illustrations 2008 vol. 25 no. 5 385-388
Bracha HS 1987 Asymmetrical rotational (circling) behavior, a dopaminerelated asymmetry: preliminary findings in unmedicated and never
medicated schizophrenic patients. Biol Psychiatry 22:995-1003.
P3-2
HYPNOTIC ATTENTIONAL STATES AND LEFT-RIGHT
ELECTRODERMAL INFORMATION TRANSFER
Lead Author: Petr Bob, Ph.D.
Co-Author(s): Ivana Siroka, MD
SUMMARY: Recent findings indicate that interhemispheric
interaction and information transition represent general
mechanisms that the brain uses across different sensory
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AMERICAN PSYCHIATRIC ASSOCIATION
hospitalization. Those who had been treated answered
questions regarding treatment satisfaction and compliance
with the MHP's recommendations. Analysis: Chi-squares
tested for relationships between patients' past month history
of suicide attempt and treatment experiences with a MHP.
Results: During the past month, 36% (n = 71) of patients
reported a suicide attempt and 57% (n = 114) had been
treated by a MHP during the month before admission.
Among those who had been treated, 70% (n = 79) found their
treatment satisfactory and 88% (n = 98) reported following
the advice of their MHP. Patients who had been treated
during the past month were not less likely to have made a
suicide attempt than those who had not been in treatment.
Of the patients who were treated, those who found their
treatment satisfactory were not less likely to have made a
suicide attempt in the past month. However, those who
complied with the advice of their MHP were significantly less
likely to have made a suicide attempt (p < 0.01, = - 0.26).
Discussion: Psychiatric treatment during the month prior to
admission and treatment satisfaction were not associated
with a reduced prevalence of suicide attempts as assessed by
the S-STS. However, patients who complied with their
MHP's advice were less likely to have made a suicide attempt
than those who did not comply. Several findings may be of
concern to clinicians. A significant percentage (43%) of
psychiatric inpatients had not been receiving treatment prior
to admission. Although the high rates of satisfaction suggest
that patients estimate their treatment to be going well,
results from the S-STS suggest otherwise. Clinicians should
consider using structured clinical interviews and efforts
should be made to encourage patients to adhere to their
treatment plan.
open-label (OL), flexible-dose, lead-in period, subjects
continued into the 12-week, OL, fixed-dose stabilization
period. Stable subjects (PANSS total score ≤ 70, YMRS ≤ 12,
and HAM-D-21 ≤ 12) were randomized (1:1) to continued PP
or PBO in the 15-month, double-blind, relapse prevention
period (RPP). Time to relapse was summarized using
Kaplan-Meier estimates. A between-group comparison was
performed using a log-rank test controlling for concomitant
medication strata. A Cox proportional hazards model was
carried out to examine treatment differences. No adjustments were made for multiplicity. Adverse events (AEs) were
summarized using descriptive statistics. Results: 667 subjects
enrolled; 334 subjects stabilized and randomized (164 to PP
and 170 to PBO) in the RPP. Mean (standard deviation [SD])
age: 39.5 (10.7) years; 54% male; 45% on PP monotherapy;
55% on adjunctive AD or MS. During the RPP, PP significantly delayed time to relapse (P < 0.001). 25 (15%) patients
relapsed in the PP arm and 57 (34%) in the placebo arm. Risk
of relapse was 2.49-fold higher for the placebo group (hazard
ratio [HR] 2.49; 95% confidence interval [CI] 1.55, 3.99; P <
0.001). In a subgroup analysis, the risk of relapse was 3.38 or
2.03 times higher for the placebo group in monotherapy or in
adjunctive AD/MS treatment, respectively (HR 3.38; 95% CI
1.57, 7.28; P = 0.002 and HR 2.03; 95% CI 1.11, 3.68; P = 0.021).
AEs occurring in >5% of patients in any group included
weight increased (PP 8.5%, PBO 4.7%), insomnia (4.9%,
7.1%), SCA (3.0%, 5.9%), headache (5.5%, 3.5%), and
nasopharyngitis (5.5%, 3.5%). Conclusion: PP as monotherapy or adjunctive to AD/MS significantly delayed relapse
in patients with SCA. When stable subjects stopped
treatment with PP (ie, PBO arm), they had a 2.49 times higher
risk of relapse than those who continued PP treatment
during the 15-month double-blind period. Support: Janssen
Scientific Affairs, LLC.
P3-6
TRAUMATIC BRAIN INJURY AND SUBSTANCE USE
Lead Author: Cheryl Ann Kennedy MD, M.D.
Co-Author(s): Jagadeesh Batana, MD
SUMMARY: Research shows that about 30-50% persons who
incur Traumatic Brain Injury (TBI) were intoxicated at the
time, mostly with alcohol, although other drugs have been
implicated. In those adolescents with TBI who require acute
inpatient rehabilitation services, up to 60% have a history of
substance use. While there appears to be a 'honeymoon'
period in the immediate aftermath and, maybe for the first
year, when substance use markedly diminishes, thereafter, a
substantial number of individuals relapse and abuse
substances. Anywhere from 35-50% of those receiving
treatment for substance use disorders (SUD) have a history
of TBI. There are multiple reasons why alcohol and other
drug use after traumatic brain injury is not recommended
and generally deleterious. This presentation will point out
major issues complicating the recovery of the brain injured
who have substances use disorders and present researched
and evidence-based strategies that can improve outcomes by
utilizing standard rehabilitation techniques from brain
rehabilitation services, as well as, substance use disorders
treatment. Part of the approach will emphasize the
importance of excellent medical care and comprehensive
evaluations to fully characterize the extent of deficits,
especially when poly-trauma has been incurred.
Additionally, practical approaches that practitioners,
families and caregivers can take to assist individuals and
themselves in facing the dual challenges of TBI and SUD
treatment and recovery will be presented.
P3-5
DO PATIENT SATISFACTION AND COMPLIANCE WITH
MENTAL HEALTH TREATMENT PRIOR TO INPATIENT
ADMISSION RELATE TO OUTCOMES ON STANDARDIZED
SUICIDE ASSESSMENT
Lead Author: Amanda M. White, B.S.
Co-Author(s): Ahmad Hameed, M.D.; Michael A. Mitchell,
M.A.; Eric A. Youngstrom, Ph.D.; Roger E. Meyer, M.D.; Alan J.
Gelenberg, M.D.
SUMMARY: Introduction: Although some clinicians avoid
standardized psychiatric assessments due to lengthy administration times, these assessments offer reliability and
validity. Structured interviews can provide a comprehensive
picture of a patient's suicidal ideation and behavior,
enabling clinicians to make informed determinations of a
patient's current risk. Unfortunately many suicidal individuals do not receive adequate treatment, leading to a higher
risk of suicidality. A secondary analysis was performed to
examine whether adult psychiatric inpatients who reported
recent psychiatric treatment, treatment satisfaction, and
compliance were less likely to have made a recent suicide
attempt. Method: Adult psychiatric inpatients (n = 199)
participating in a psychometric evaluation study completed
a standardized suicide assessment measure, the SheehanSuicidality Tracking Scale (S-STS) as a self-report or clinical
interview and an investigator-designed Risk Assessment
Measure (RAM). The S-STS inquired about past month
history of suicide attempt. During the RAM, patients
indicated whether they had been treated with a mental
health professional (MHP) during the month prior to
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
ment failure. Methods: PRIDE is a 15-month, randomized,
open-label, multicenter US study comparing PP with oral
APs in a community sample of schizophrenia subjects with a
history of incarceration (NCT01157351). The primary study
end point was "time to treatment failure" (defined as any 1 of
the following: arrest/incarceration, psychiatric hospitalization, suicide, treatment discontinuation or supplementation due to inadequate efficacy, safety or tolerability, or
increased psychiatric services to prevent hospitalization as
determined by a blinded event monitoring board) analyzed
by the Kaplan-Meier method with a log-rank test for treatment group difference. An exploratory analysis used the
pooled data to examine the effect of substance abuse on
treatment failure. Results: Primary Study Outcomes: 444
subjects were included: 226 randomized to PP and 218 to
oral APs. PP was associated with a significantly longer time to
treatment failure versus oral APs (log-rank P = 0.011).
Median (95% CI) time was 416 days (285, >450) in the PP
group and 226 days (147, 304) in the oral AP group. The most
common treatment-emergent adverse events (AEs) in the PP
versus oral AP groups were injection site pain (18.6% vs 0%),
insomnia (16.8 vs 11.5%), weight increase (11.9% vs 6.0%),
akathisia (11.1% vs 6.9%), and anxiety (10.6% vs 7.3%).
Exploratory Effect of Substance Abuse: 264 (59.5%) were
substance abusers and 180 (40.5%) were not substance
abusers. Median (95% CI) time to treatment failure was 260
days (156, 314) in the substance abuse cohort and could not
be determined (>450 days) in the no substance abuse cohort.
The most common AEs in the substance abuse versus no
substance abuse cohort were insomnia (14.8% vs 13.3%),
akathisia (10.2% vs 7.2%), and injection site pain (11.0% vs
7.2%). Conclusions: In this clinical trial of schizophrenia
subjects with a history of incarceration, PP significantly
delayed treatment failure versus daily oral antipsychotics.
More than half of the population was identified as substance
abusers. An exploratory analysis showed that substance
abuse was associated with shorter time to treatment failure.
Support: Janssen Scientific Affairs, LLC
P3-7
DO PSYCHOSTIMULANTS HAVE A ROLE IN TREATING
DEPRESSION SYMPTOMS IN CANCER PATIENTS? A METAANALYSIS
Lead Author: Joy Chang, M.D.
Co-Author(s): Patrick Cleary, MD; Sarosh Nizami, MD; Seth
Himelhoch, MD, MPH
SUMMARY: Background/Objectives: Psychostimulants are
frequently used to treat fatigue and depressive symptoms in
a wide spectrum of medical illness. This study aims to
investigate the efficacy of psychostimulants on depressive
symptoms in cancer patients in comparison to controls that
received placebo and standard of care treatment for their
cancer type. Methods: Electronic databases (Embase, PsycInfo, PubMed), bibliographies and gray literature were
searched January 1, 2014. Subject search terms included the
following and related terms: psychostimulants, depression
and cancer. No publication date criterion was used. All
studies were randomized, double-blind and placebocontrolled study of the efficacy of CNS stimulants in the
reduction of depression in adult cancer patients. Of the 121
studies, 4 (3.3%) met selection criteria. Study quality was
assessed independently by two authors using the Cochrane
approach and the inter-rater reliability was found to be
Kappa = 0.952. Outcome data describing baseline and endpoint depression in intervention and control groups were
extracted independently by one author and reviewed by a
second author. Results: Meta-analysis of 4 studies evaluating
the efficacy of psychostimulant medication on depression
symptoms in adults with cancer did not show a statistically
significant effect in depression symptom reduction. Effect
size was small, with an overall SMD of 0.11 (95% CI -0.03,
0.24). No publication bias or heterogeneity found. Discussion: Though there is a demonstrated small effect size, our
meta-analysis shows no statistically significant advantage to
using psychostimulants in the treatment of depression
symptoms in cancer patients. Included studies were limited,
however, to cancer patients in active treatment; available
literature suggests patients with end-stage prognosis and
receiving palliative care may experience anti-depressive
benefit from the rapid onset of CNS stimulants. Further
investigation is necessary.
P3-9
INCREASING CLOZAPINE USE AT A FORENSIC STATE
HOSPITAL
Lead Author: Rebecca Kornbluh, M.D.
Co-Author(s): Jonathan Meyer, MD; Michael Cummings, MD;
George Proctor, MD
SUMMARY: Background: Clozapine is an antipsychotic most
commonly used for the treatment of psychosis when other
treatments have failed. In addition to having superior
efficacy to other antipsychotics for refractory schizophrenia,
clozapine has been shown to decrease criminal recidivism,
decrease suicide, and decrease violence. The impact on
violence is often independent of clozapine's effect on any
psychotic symptoms. In spite of its proven efficacy, clozapine is frequently under-prescribed. With clozapine's
generic availability, usual CME sources do not provide the
educational support given to newer medications. In the
California Department of State Hospitals (DSH), the largest
forensic hospital system in the United States, chronic underprescribing of clozapine has been observed. In spite of a
largely treatment refractory patient population, many with a
history of violence, the rate of clozapine prescription at DSHPatton was between 6 and 7%. Methods: DSH psychopharmacology leadership developed an educational program
that focused on basic elements of clozapine prescribing.
Initial lectures focused on the evidence-based rationale for
P3-8
PALIPERIDONE PALMITATE RESEARCH IN
DEMONSTRATING EFFECTIVENESS: MANAGING
SCHIZOPHRENIA PATIENTS WITH A HISTORY OF
INCARCERATION AND SUBSTANCE ABUSE
Lead Author: H. Lynn Starr, M.D.
Co-Author(s): Lian Mao; Jean-Pierre Lindenmayer; Steven
Rodriguez; Larry Alphs
SUMMARY: Background: The fragmented mental healthcare
system in the United States and gaps in care contribute to
inadequate management of patients with schizophrenia.
Care is often complicated by comorbid conditions such as
substance abuse, which is associated with more severe and
treatment-resistant schizophrenia, longer hospital stays, and
increased risk of criminal justice system (CJS) involvement.
The Paliperidone Palmitate Research in Demonstrating
Effectiveness (PRIDE) study examined the effects of oncemonthly paliperidone palmitate (PP) and daily oral antipsychotics (APs) on treatment failure in subjects with
schizophrenia and a history of recent CJS involvement who
were receiving antipsychotic treatment. An exploratory
analysis examined the impact of substance abuse on treat93
AMERICAN PSYCHIATRIC ASSOCIATION
tant BED diagnostic criteria (eg, loss of control eating), they
commonly did so in relation to patient weight and perceived
lack of self-control. In diagnosis conversations, doctors did
not assess all DSM-5 criteria. Alternately, patients attempted
to clarify the relationship among feelings, coping strategies,
and compulsion to binge. With their focus on weight and
self-control, many doctors recommended willpower and
behavioral substitution to prevent binge episodes. Our
findings suggest that future communication guides should
define DSM-5 criteria and stress the importance of assessing
patient emotion, loss of control eating, and the relationship
between body weight and BED.
prescribing clozapine to many of the DSH patients.
Subsequent lectures focused on specific strategies for
clozapine titration and management of side effects.
Additional support of clozapine use was provided through
shared success stories and reports to nursing staff. Results:
Immediately following the lecture series, an initial increase
of 40% in prescribing was observed. This increase was
statistically significant (P < 0.05). Interestingly, the rate of
clozapine prescribing continues to rise, even six months
after the intervention. Current use shows an overall increase
of 57%. Conclusions: An educational intervention was highly
successful in increasing state hospital clozapine use more
than 50%. The impact of education was seen directly
following the lectures and also persisted up to six months
after the lectures. In-house lectures and support can
compensate for educational deficits.
P3-11 WITHDRAWN
P3-12
{+/-}3,4-METHYLENEDIOXYMETHAMPHETAMINE IN
COMBAT RELATED PTSD: A REVIEW AND COMPARISON
WITH AND WITHOUT PSYCHOTHERAPY
Lead Author: Cole J Marta, M.D.
Co-Author(s): Benjamin Schechet, BA.; Wesley C. Ryan, MD;
Ralph J. Koek, MD
SUMMARY: Until its criminalization in 1985, +/-3,4-methylenedioxymethamphetamine (MDMA) was used as pharmacotherapy by psychiatrists. After more than 25 years,
Mithoefer et al performed the first clinical trial evaluating
MDMA as adjunct treatment was reported in the literature.
This clinical trial demonstrated significant improvement in
Clinician-Administered PTSD Scale (CAPS) when MDMA was
administered in conjunction with psychotherapy in limited
sessions as part of a longer course of psychotherapy. These
treatments were provided without evidence of harm in
patients with refractory PTSD. Other studies utilizing MDMA
for PTSD with and without psychotherapy, a follow up of
Mithoefer's study, and preliminary results of a second
Mithoefer study were reviewed. We compare results
regarding safety and efficacy, as well as techniques utilizing
different psychotherapies, to include no psychotherapy.
Results show that MDMA utilized outside of a psychotherapy
session did not show significant improvement in CAPS
scores. Significant improvement was demonstrated repeatedly, and with evidence of lasting effect, by the Mithoefer
group which was not repeated when utilizing prolonged
exposure therapy (PE).
P3-10
COMMUNICATION BETWEEN PSYCHIATRISTS AND
PATIENTS WITH SUSPECTED OR DIAGNOSED BINGE
EATING DISORDER: DIFFERENCES IN PERSPECTIVE
Lead Author: Susan G Kornstein, M.D.
Co-Author(s): Paul E. Keck, Jr, MD, Barry K. Herman, MD,
MMM, Rebecca M. Puhl, PhD, Denise E. Wilfley, PhD, Ilyse D.
DiMarco, PhD, Ellyn S. Charap, MS
SUMMARY: Background: Effective doctor-patient communication is essential to diagnosis, evaluation and treatment of
eating disorders. Doctors and patients may be unaware of
Binge Eating Disorder (BED) as a new distinct disorder in
DSM-5, potentially leading to inadequate communication
around diagnosis and treatment. Our objective was to
examine doctor-patient conversations about BED, identify
evaluation gaps, and develop conversation guides that lead
to optimal communication and relationships. Methods: We
recorded, transcribed and conducted content analysis on 38
doctor-patient conversations (38 suspected/diagnosed BED
patients, 11 psychiatrists) from across the US. Average
patient age was 37; 32% were male. We reviewed transcripts
for lexical terms related to diagnosis and treatment of BED;
searches were automated using conversation analysis
software. In addition to automated searching, researchers
read through conversations to disambiguate multivalent
terms (eg, sweet food vs sweet disposition) and combined
similar terms (eg, binge, bingeing) into one term (binge). We
then assessed differences in the frequency and type of terms
used by doctors vs patients to uncover communication gaps.
Results: Term frequency, type, and number of uses differed
between doctors and patients. During evaluation, doctors
assessed absence of compensatory behavior (2 terms,12
unique uses) but did not ask about eating more rapidly than
normal or secretive eating. Additionally, doctors asked more
often about type of food consumed than about amount
(13,25 vs 9,17) or about out of control eating (4,7). Although
most doctors did assess distress (9,25) and eating past
fullness (5,12), they did not assess these as independent
criteria. Rather, most doctors asked about distress and eating
past fullness in relation to weight and self-control, eg, "Are
you upset about gaining weight?" and "How else did you
cheat?". Doctors initiated discussion of weight (21,59) more
often than patients (3,13). Patients used emotional (27,39),
coping (13,30) and terms describing compulsion (20,32)
more often than doctors when discussing binge episodes. In
discussing ways to prevent binge episodes, doctors focused
on self-control and substitution (13,18) in addition to other
therapies. Conclusions: While doctors did evaluate impor-
P3-13
DOES THE USE OF DEPOT MEDICATION IMPROVE
ADHERENCE WITH POST-HOSPITALIZATION CLINIC
APPOINTMENTS?
Lead Author: Abosede Adekeji Adegbohun, M.B.B.S.
Co-Author(s):Increase I. Adeosun, M.D.; A. Fadahunsi, M.D;
A.O. Pedro, M.D.
SUMMARY: Introduction: Nonadherence with post discharge clinic appointment is a major concern among
clinicians and health service policy makers. The gains
achieved during psychiatric hospitalization may be eroded
due to non compliance following discharge from the
hospital. The impact of depot medications on compliance
with post discharge clinic appointments has not been well
researched in Nigeria. Objective: The study determined the
impact of depot medications on adherence with post
hospitalization clinic appointments. Others correlates of
post hospitalization clinic adherence were also assessed.
Methods: The clinical records of patients (n=273) discharged
from the Psychiatric Hospital, Yaba, were reviewed. The
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
failed to meet significance (r = 0.11, p = 0.41). Discussion:
Although adult psychiatric inpatients who used alcohol did
not score significantly higher on the suicidal behavior
subscale of the S-STS, alcohol users who binged at least once
a month did score significantly higher than those who did
not binge. There was also a significant correlation between
number of days spent binge drinking and suicidal behavior
score, though this effect was largely driven by females. To
our knowledge, no previous studies have examined
relationships between alcohol use, binge drinking, and
suicidality outcomes using the S-STS. Psychiatric patients
who binge drink, particularly females, may be at a higher risk
for suicidal behavior than psychiatric patients who do not
binge drink.
following variables were extracted: socio-demographic
characteristics, use of depot medication, compliance with
post discharge clinic appointments and clinical characteristics. The data were analysed with SPSS version 20. Results:
The sample consisted of 35% males, with a mean age of 39.26
(±12.36) years. 39.6% (106) of the sample were on depot
medications. There was no significant association between
use of depot medication and adherence with post
hospitalization clinic appointments (p=0.173). Poor adherence with clinic appointment was associated with longer
duration of illness (p=0.008), presence of psychosis
(p=0.031), and class of antipsychotic medications (p=0.037).
Conclusions: This study found no significant relationship
between use of depot medication and adherence with post
hospitalization clinic appointments.
P3-15
EVALUATING MOBILE MENTAL HEALTH SMARTPHONE
APPLICATIONS: CURRENT EVIDENCE AND CRITERIA
Lead Author: Steven Chan, M.B.A., M.D.
Co-Author(s): John Torous MD; Ruth Hsu, BS; Peter Yellowlees
MD, MBBS
SUMMARY: OBJECTIVE / BACKGROUND: Smartphones are
ubiquitous in American society and are increasingly being
used amongst psychiatric patients. Their versatility as a
mobile platform can extend mental health services, but the
efficacy and reliability of publicly-available applications has
yet to be demonstrated. The marketplace has already
produced thousands of psychiatric-related applications that
clinicians currently have no guidance or tools to evaluate.
METHOD: A literature search was conducted within
PubMed, Psycinfo, and engineering journal databases
(Embase, IEEExplore) to determine the extent of academic
efforts of evaluating smartphone applications in the areas of
security, usability and clinical validity & reliability. We also
analyzed methods used to evaluate other types of nonsmartphone software in the realm of clinical informatics,
telemedicine, and other systems. We also performed an
industry analysis by searching news articles and press
releases determine the extent of commercial and non-profit
organizations' efforts to evaluate and review applications.
RESULTS: The current academic literature recognizes the
lack of effective criteria for judging mobile applications and
its negative effects. This problem of judging mobile
applications does not appear to be unique to psychiatry but
rather reflective of almost every medical speciality.
Commercial efforts by organizations such as Happtique and
HealthTap have had limited success. No set of selfcertification standards has been approved or by any medical
society or governing body, including the American
Psychiatric Association, American Psychology Association,
National Alliance on Mental Illness, and the Substance
Abuse and Mental Health Services Administration. Our
results based on the literature search propose criteria for
mobile mental health smartphone applications based on
industry practices and computer science literature
evaluating practical, safe, usable applications. CONCLUSION: The field of psychiatry has no current way of comparing, validating, regulating, or approving of the very
applications developed to assist the field. Our publication
proposes a robust framework for evaluating such
applications that can be applied by consumers of and
practitioners recommending such applications.
P3-14
IS BINGE DRINKING ASSOCIATED WITH AN INCREASE IN
SUICIDAL BEHAVIOR IN ADULT PSYCHIATRIC
INPATIENT POPULATION AS ASSESSED BY S-STS?
Lead Author: Ahmad Hameed, M.D.
Co-Author(s): Amanda M. White, B.S.; Michael A. Mitchell,
M.A.; Eric A. Youngstrom, Ph.D.; Roger E. Meyer, M.D.; Alan J.
Gelenberg, M.D.
SUMMARY: Introduction: Alcohol use and binge drinking are
significant risk factors for suicide in non-clinical samples.
However few studies have addressed this question in
psychiatric inpatients, who are at higher risk for suicide than
the general population. Furthermore, studies in non-clinical
samples have typically relied on unstandardized measures of
suicidal behavior. The current study examined the relationship between alcohol use, binge drinking, and suicidal
behavior in adult psychiatric inpatients using a standardized
suicide assessment. Method: Participants were adult psychiatric inpatients enrolled in a psychometric evaluation study
(n = 199; 43.2% male, 56.8% female). During the Sheehan
Suicidality Tracking Scale (S-STS), patients reported their
past month history of suicidal behavior. Approximately half
of patients completed the S-STS as a clinical interview; the
remainder completed the S-STS via self-report. A Risk
Assessment Measure (RAM) asked patients whether they
drank alcohol and if so, how many days they binge drank
each month. Analysis: Analyses of variance (ANOVAs) were
conducted to test for (1) main and interaction effects of
gender and alcohol use on score on the S-STS suicidal
behavior subscale and (2) to test for main and interaction
effects of gender and binge drinking on suicidal behavior
score. Correlations were made between the number of days
of binge drinking and suicidal behavior score. Results:
Approximately half of all patients reported alcohol use;
males were slightly more likely to use alcohol. Alcohol use
and gender did not have significant main effects on suicidal
behavior score. No significant interaction emerged. Half of
all drinkers binge drank at least once a month; males and
females were equally likely to binge. Those who binge drank
in the past month scored significantly higher on the suicidal
behavior subscale than those who did not binge drink (p =
0.01). There was no significant interaction effect. There was a
small but significant positive correlation (r = 0.21, p = 0.03)
between the number of days drinkers binged and suicidal
behavior score. Among women, this correlation was
moderate (r = 0.35, p = 0.01). Among men the correlation
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AMERICAN PSYCHIATRIC ASSOCIATION
symptoms, depression stigma, and goal self-efficacy were
consistently associated with endorsement of structural
barriers to care. We found higher levels of stigma were
associated with lower number of endorsed barriers to care
(beta= -.25, t(79) = -2.79, p =.007). Higher self-efficacy was
also significantly associated with lower number of barriers to
care (beta = -.30, t(79) = -2.78, p =.007). Depressive
symptoms were weakly associated with number of barriers
endorsed (beta = -.08, t(79) = 1.98, p = 0.05). Domestic
violence and social support were not associated with
number of barriers endorsed. This model explained a
significant proportion of the variances in number of
structural barriers endorsed, R2 = .41, F(8 , 70) = 8.46, p <
.001. Conclusion Low-income women in Vietnam face
numerous structural barriers to mental health care. Although
seemingly fixed barriers, stigma, depressive symptoms, and
goal self-efficacy may modulate the perception of structural
barriers. Public health interventions should consider these
factors to better deliver mental health care to underserved
populations.
P3-16
RECOGNITION OF SYMPTOMS OF PSYCHOSIS AMONG
SECONDARY SCHOOL STUDENTS IN LAGOS, NIGERIA
Lead Author: Abosede A. Adegbohun, MD
Co-Author(s): Increase I. Adeosun, MD; Olufemi Oyeleke
Oyekunle, M.B.B.S.; O. Jeje, MD; Bayo Jejeloye, MD
SUMMARY: Introduction: Previous researches have
highlighted the importance of good mental health literacy
among lay people as pivotal to recognising early psychotic
symptoms, culminating in early presentation to mental
health care services. Objectives: This study assessed the
extent to which secondary school students in Lagos, Nigeria
were able to recognise symptoms of psychosis. Methods: 305
senior secondary school students randomly selected from 3
private and public secondary schools in Lagos, Nigeria were
presented with vignettes describing various psychotic
symptoms in order to assess their level of literacy about
psychosis. Results: The mean age of the participants was
14.99 (±1.58) years and 45.6% (140) of them were males. Of
the 305 participants, only 46.3% (142) were able to recognise
auditory hallucination as a psychotic symptom, while 43%
(132), 44% (135), and 47.9% (147) were able to recognise
suspiciousness, unusual thought content, and conceptual
disorganisation respectively as psychotic symptoms. There
was no significant statistical difference between level of
mental health literacy among students in public and private
senior secondary schools (p>0.05). Conclusions: Less than
half of the participants were able to recognise symptoms of
psychosis. This highlights an urgent need to integrate mental
health education to the curriculum of secondary school
education in Nigeria. Increasing mental health literacy
among secondary school students will improve their ability
to recognise psychotic symptoms and facilitate the desired
health seeking behaviour among lay people.
P3-18
COERCION AND COMPULSORY PSYCHIATRIC
COMMUNITY TREATMENT ORDERS: A REVIEW OF
PATIENT PERCEPTIONS OF TREATMENT
Lead Author: Arash Nakhost, Ph.D.
Co-Author(s): Ms Kate Francombe Pridham; Andrea Berntson,
MD; Sandy Simpson, MD; Samuel Law, MD; Lorne Tugg, MD;
Vicky Stergiopoulos, MD
SUMMARY: The use of compulsory psychiatric community
treatment orders (CTOs) is common in many countries, with
variations in legislation. However, these orders remain
contentious, due to the ethical implications of coercing
patients to receive treatment. Understanding patient
perceptions of these practices can assist in the development
of more patient-centered and recovery-focused community
psychiatric care. This poster presents the findings of a
literature review which investigated the results of all
quantitative and qualitative studies reporting on coercion
and CTOs. Twenty-three articles reporting on results of
fourteen studies from seven countries are summarized.
Factors influencing patient perceptions of coercion are
explored in relation to the CTO legislation and practice in
study jurisdictions. Recommendations are put forth for
engaging in compulsory community psychiatric care in ways
which maintain a strong therapeutic relationship and
minimize the coercive impact on patients.
P3-17
BARRIERS TO MENTAL HEALTH CARE AMONG LOWINCOME WOMEN IN VIETNAM
Lead Author: Kunmi Sobowale, B.A.
Co-Author(s): Victoria Ngo, PhD; Lam Tu Trung, MD; Tran
Nguyen Ngoc, MD; Tran Hai Van, MD; Bahr Weiss, PhD
SUMMARY: Background Despite an increased risk to develop
common mental disorders, impoverished and low-income
women are less likely to receive mental health care. In order
to better understand the barriers to care these women face,
we assessed structural barriers to care (i.e., it is difficult to
schedule an appointment) in a low-income population in
Vietnam and tested the hypothesis that these barriers would
be more common among patients with depression.
Methods We interviewed 79 low-income (monthly family
income < $95 per capita) women presenting at four primary
care clinics in Vietnam following enrollment in a randomized control trail. We assessed for structural barriers to care
(7-item questionnaire), depressive symptoms (Patient
Health Questionnaire-9), diagnosis of depression (MINI 6.0),
Medical Outcomes Study SF-12, quality of life (Quality of Life
Enjoyment and Satisfaction Questionnaire Short Form),
personal depression stigma (Depression Stigma Scale),
domestic violence (HARK), social support (MOS support
social) mental health literacy and goal self-efficacy
(measured by 4-item questionnaire). We used multivariable
regression to analyze the data. Results Eighty-five percent of
women endorsed at least 1 barrier to care. The most
frequently endorsed structural barrier was "my health plan
wouldn't pay for treatment," (63%, n = 50). Depressive
P3-19
IS IT ETHICAL TO USE VALPROATE (CATEGORY D) IN
WOMEN OF CHILD BEARING AGE?
Lead Author: Asim A. Shah, M.D.
Co-Author(s): Roopma Wadhwa MD, MHA; Vikas Gupta MD,
MPH; Valeria M. Contreras, MD
SUMMARY: Objectives: To discuss the management of
bipolar disorder in women of reproductive age; to discuss
the management of acute mania not fully responsive to
mood stabilizer; and to address the management dilemma to
use valproate for high risk reproductive age women.
Background: Bipolar disorder is more common in women
and its management in reproductive age women is of utmost
concern. Per 2006-2010 National Survey of Family Growth
conducted by the Centers for Disease Control and
Prevention's National Center for Health Statistics, around
37% pregnancies are unintended in U.S. Moreover, majority
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
enrolled in the University, and he was not able to complete
the course because "I had no privacy", the patient was
manifesting features of paranoid delusions, when inquired
he stated, "they were reading my e-mail, Facebook", and" my
phone was being tapped, and "that's why I left the
university." After two courts hearings, for retention and
treatment over objection, he started taking medications
without any adverse effects. He was later discharged from
the inpatient unit to his mother, with appointments to the
outpatient Clinic After attending several sessions in the
outpatient clinic, his psychotic symptoms improved, but
over the course of time he expressed to his psychiatrist that
he was experiencing severe depression and hopelessness. He
mentioned that he has suicidal thoughts every day but he
has not made any further attempts to end his life. He was
admitted and an anti-depressant added to his regimen.
Patient now is more aware that he was living a life of fantasy
before and now he looks back and feels that he has not been
successful in achieving his goals. Discussion Depressive
symptoms with schizophrenia range from 6 to 75 percent
[3,4], and studies have found that 25% lifetime prevalence,
well above the general population [5]. Suicide is also a bad
impact on this population as they are expected to die much
earlier [6] with a 4.9% lifetime suicide completion risk [7].
The patient described above was admitted to the inpatient
unit with a diagnosis of schizophrenia and treated accordingly. At the time of discharge he began to realize that he was
living a life of fantasy. Due to a strict continuity of care he
was able to discuss his feeling of depression and thoughts of
suicide with his psychiatrist and avoided grave outcome was
avoided. Conclusion People with schizophrenia, because of
higher risk of lengthier stay in the hospital, and increased
risk of suicide over the general population, require a very
well thought out follow-up care, after being discharged.
of teratogenic side effects occur in the early first trimester.
We report a case of bipolar disorder who demonstrated
manic symptoms resistant to initial therapy with
risperidone. Case: A 25 year old female with history of
bipolar disorder was brought to the emergency for agitation,
bizarre behavior, flight of ideas, irritability, mood lability and
delusions. She was loud, hypertalkative with pressured
speech, and was removing her clothing. She had a past
history of manic episodes previously treated with valproate.
She had unprotected sex with multiple partners over last 3
weeks and did not remember her last menstrual period.
Emergency I/m sedation was given. Mental status exam
showed uncooperative and hostile behavior with a 'great'
mood, labile affect; thought process was disorganized and
difficult to follow. She had poor insight, poor judgment, and
poor attention with no suicidal or homicidal intent. Patient
had active hallucinations as well as paranoid and grandiose
delusions. Urine pregnancy test was negative. She was
admitted to inpatient unit. Risperidone was started which
was titrated to 3mg BID over first week of hospitalization.
Psychosis improved but still aggressive, irritable with a
decreased need for sleep, thus valproate was initiated 2000
mg qhs. Manic symptoms improved but the patient
mentioned that she might be pregnant. The initial urine
pregnancy test was negative but since it was drawn too early,
valproate was stopped with the suspicion of her being
pregnant. Risperidone was started; urine pregnancy test was
repeated and it was negative. Her symptoms worsened again
for few days. Valproate was restarted and her symptoms
improved significantly for almost 3 weeks. Discussion:
Valproate is considered in bipolar disorder cases that do not
show a promising response to atypical anti-psychotics. The
use of valproate presents a challenge in the reproductive age
women due to its high potential for teratogenicity which
necessitates consideration of better and safer alternate drug
treatments. Conclusion: Due consideration should be taken
prior to prescribing valproate in reproductive age women
with bipolar disorder. Pregnancy testing sometimes may be
done early in pregnancy around unprotected intercourse
which may mandate repeat pregnancy tests as well as
ultrasound later in the second trimester to be more
confident of a woman's gravid status.
P3-21
ATYPICAL SELF-HARM: TWO CASE REPORTS OF
UNUSUAL SELF-HARM METHODS
Lead Author: Nidal Moukaddam, M.D., Ph.D.
Co-Author(s): Mollie Gordon, MD, Amy Vyas, MD
SUMMARY: Background: Non-suicidal self-harm has been
described for thousands of years, and has evolved with
society in terms of scope and significance. In modern times,
non-suicidal self-harm has fluctuating rates, and tends to
afflict both genders, though is stereotypically thought of as
more common in females. Most common methods of selfharm include cutting, scratching, superficial biting and
burning, though socially sanctioned methods are everexpanding. Case descriptions: This presentation will report
on two patients, both males in their 20's, who were seen in
the emergency room for suicidal ideations. On history
taking, unusual self-harm methods were elucidated. Case 1:
history of self-harm since childhood by biting veins until
severe bleeding occurs. Had been hospitalized on medical
basis because of blood loss. Reported a pleasurable, almost
paroxysmal-like experience while biting. Case 2: history of
self-harm via various methods, but focused on burning with
dry ice. Patient was interestingly able to contrast various selfharm methods and praises dry ice burns as more effective for
relieving emotional pain. Outcomes and Discussion:
Encountering other methods of self-harm typically elicits
further inquiry into the disorder at hand and possibility of
substance use and cognitive deficits. Inhalant use, traumatic
brain injury as well as underlying psychotic disorders and
other medical considerations have to taken into account.
P3-20
POST-SCHIZOPHRENIC DEPRESSION AND THE
IMPORTANCE OF CONTINUITY OF CARE
Lead Author: Demetrio J Prota, M.D.
Co-Author(s): Muhammad Waseem MD.; Steven Vargas MD
SUMMARY: Introduction Outpatient follow-up has been well
known to improve outcome in all patients after they have
been discharged from an inpatient unit, not to mention
reduction in successful suicides and re-hospitalizations. A 5
year follow-up study conducted in Finland demonstrated
that "the mortality rates and number of psychiatric
treatment days and relapses during the 5-year follow up were
notably lower"[2]. The mortality was 5.3% among hospitalized patient vs 3.8%, and the risk of relapse was 39.6% for
outpatient's vs 74.2% [2]. Case This is a 37 year-old Hispanic
man, single, domiciled, unemployed, educated with degree
in philosophy with unclear psychiatric history, was brought
from The George Washington Bridge (side road), where he
states he was sitting, "thinking about many things". He was
threatening to jump off of the edge as NYPD approached
him. Patient initially stated that "they were coming to me [to
deprive me of my freedom"]. The patient at that time was
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AMERICAN PSYCHIATRIC ASSOCIATION
adherence to the Health Buddy device. In both groups, we
assessed suicidal ideation (Scale for Suicide Ideation) and
depression symptom (Calgary Depression Rating Scale)
scores at baseline, 2, 4, 8 & 12 weeks post discharge. Results:
Fifteen out of 25 participants were randomized to HB and 10
were randomized to UC. Fourteen out of 15 HB participants
were able to set up the device and use it. Of those who used it
over the 3 month period, the average daily adherence in the
use of HB system was 85.5%. While subjects in both groups
had decreases in the SSI scores after discharge, only subjects
in the HB group sustained the decrease over 12 weeks. In the
Health Buddy group the decrease in scores was maintained
through 12 weeks post discharge while the Usual Care group
returned to baseline levels of suicide ideation by week 12
(time by treatment group interaction [F = 5.28; df = 1, 68; p <
0.05]). There were no differences between groups in patterns
of depressive symptom scores. Conclusions: Telehealth
monitoring for this population of patients appears to be
feasible and effective at reducing post discharge recurrences
of increased levels of suicide ideation. Larger studies are
needed to replicate these findings. The views do not reflect
the views of the US government or that of the US
Department of Veterans Affairs.
Further, as lethality of unusual self-harm methods, correlates
and rates of recidivism are very poorly understood, the need
for careful history-taking cannot be overstated.
P3-22
WEIGHT GAIN ASSOCIATED WITH ARIPIPRAZOLE
ADJUNCTIVE TO ANTIDEPRESSANTS
Lead Author: Robert G. Bota, M.D.
Co-Author(s): Charles Nguyen, MD
SUMMARY: Objective: 5-HT2C receptor antagonists are
thought to contribute toward increased appetite and obesity.
Aripiprazole acts as a partial agonist at the 5-HT2C receptor;
hence, it is thought to cause little or no significant weight
gain when used alone. We theorize that, in the presence of
antidepressants with high serotonergic activity, aripiprazole
acts as an antagonist at the 5-HT2C receptor, thus increasing
the potential for weight gain. Conversely, in environments
with low serotonergic activity, aripiprazole acts as an agonist
at the 5-HT2C receptor, therefore having less potential for
weight gain. Method: A retrospective electronic medical
record chart review of the Veterans Integrated Service
Network 22 Veterans Affairs database was performed comparing patient's weight and body mass index (BMI) while
taking aripiprazole alone (n = 1,177), aripiprazole plus highserotonergic antidepressants (citalopram, fluoxetine, paroxetine, sertraline, and venlafaxine) (n = 145) versus
aripiprazole plus a low-serotonergic antidepressant (bupropion) (n = 77) for a minimum continuous duration of 6
months of aripiprazole monotherapy or combination
treatment. The study was conducted from January 2010
through June 2011. Results: In our patient population, only
the aripiprazole plus high-serotonergic antidepressants
group had a statistically significant increase in weight (P =
.0027) and BMI (P = .0016). Conclusions: Our data suggest
that, in the presence of antidepressants with high serotonergic activity, aripiprazole may act as an antagonist at the 5HT2C receptor, resulting in weight gain. Conversely, when
aripiprazole is used in the presence of antidepressants with
low serotonergic activity, it may act as an agonist and result
in little or no weight gain. This varying effect at the 5-HT2C
receptor may explain why aripiprazole has not been
associated with significant weight gain in previous studies
focusing on schizophrenia and bipolar disorder.
P3-24
SYMPTOM SEVERITY AND FUNCTIONING IN SUBTHRESHOLD POSTTRAUMATIC STRESS DISORDER
Lead Author: John Kasckow, M.D.
Co-Author(s): D Yaeger, K Magruder
SUMMARY: There are no agreed upon criteria for defining
subthreshold Posttraumatic Stress Disorder (PTSD). Four
definitions were compared in their ability to distinguish
subthreshold individuals from those with or without PTSD in
815 primary care veterans. We compared PTSD Checklist
(PCL) scores and Medical Outcomes Study Short Form 36 (SF
36) mental health and physical health composite scores
between participants meeting criteria for one of the
subthreshold PTSD definitions (based on Schnurr, Marshall,
Blanchard, or Stein) to those with and without PTSD. Using
regression and controlling for age and gender, those meeting
subthreshold criteria by any of the 4 definitions had lower
mental and physical health functioning and higher PCL
scores relative to those without PTSD. Those participants
meeting subthreshold criteria by any of the 4 definitions also
had higher mental health functioning and lower PCL scores
relative to those with PTSD. With SF 36 physical functioning
scores, only those meeting the Stein definition differed from
the group with PTSD. Thus, these definitions appear to
distinguish individuals who are qualitatively different from
individuals with no PTSD or with PTSD and are nearly
equivalent in their ability to discriminate individuals with
PTSD or no PTSD.
P3-23
MONITORING SUICIDAL VETERNS WITH
SCHIZOPHRENIA USING TELEHEALTH
Lead Author: John Kasckow, M.D.
Co-Author(s): A Rotondi, S Gao, B Hanusa, L Fox, S
Zickmund, M Chinman, GL Haas
SUMMARY: Objectives: A Health Buddy© telehealth system
was developed to augment Usual Care for Veterans with
schizophrenia who were recently discharged from the
hospital. The purpose of the telehealth system was to
monitor suicidal risk following hospitalization for suicidal
behavior. We tested whether telehealth monitoring in this
population would be feasible. We also tested whether
augmentation of Usual Care with telehealth monitoring
would result in a lower levels of suicidal ideation and
depresssive symptoms in the 12 weeks following hospital
discharge. Methods: Veterans with schizophrenia/schizoaffective disorder admitted for suicidal behavior were
recruited into a post-discharge program consisting of VA
Usual Care with daily Health Buddy telehealth monitoring
(HB) or VA Usual Care alone (UC). We tracked levels of daily
P3-25
DOES CHILDHOOD PHYSICAL OR SEXUAL ABUSE LEAD
TO AN ADULT BODY HABITUS?
Lead Author: Ranjan Avasthi, M.D.
Co-Author(s): Anthony Ahmed, PhD; Katherine Thomas, MS
SUMMARY: Georgia Regents University Department of
Psychiatry and Health Behavior Division of Child and
Adolescent Psychiatry at the Medical College of Georgia
Background: The mental health ramifications of childhood
abuse have been previously examined. Another well-studied
and significant public health concern is the rising incidence
of obesity. This paper considers the plausible link between
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
been completed in national and international conferences.
Depression screening in primary care setting and in various
clinical settings using PHQ9 was completed internationally.
CLM's strategic planning team has also established GMH
Caucus within the APA. Conclusion: Addressing issues for
GMH with the involvement of residents from a district
branch of APA is an innovative approach. Along with
addressing important issues in the field, through mentorship
and direct participation, this model provides opportunity for
resident physicians to become culturally competent leaders
in diverse systems of care.
References:
these two areas of research. Objective: This study examines
the long-term health problems of early life trauma and
obesity to determine if a correlation exists between these
different variables. Methods: The source of data for this
paper is an epidemiological study, conducted by the
National Centre for Social Research (NatCen) in cooperation
with the University of Leicester and funded by the National
Health Service (NHS), and data was collected using the Adult
Psychiatric Morbidity Survey (APMS). For the purpose of this
paper, four questionnaires are examined: The Short Form 12
(SF-12), which is a health survey created for the Medical
Outcomes Study (MOS), the Trauma Screening Questionnaire (TSQ), the List of Threatening Experiences (LTE), and
the SCOFF screen addressing eating disorders. Data from the
questionnaires were analyzed using (SPSS) software for
statistical analysis, to conduct logistic regressions to search
for possible associations between the study variables.
Results: There was a positive association between participants who experienced sexual intercourse without consent
before the age of 16 and a BMI of > 30 (OR 2.388, 95% CI
1.669 – 3.417, p < 0.001) for both men and women. For
people in this survey who were touched in a sexual way
without consent before age of 16 also had a significant
relationship with an obese BMI of > 30 (OR 1.524, 95% CI
1.254 – 1.852, p < 0.001). Physical abuse before the age of 16
also proved to have a positive association with a BMI > 30
(OR 1.778, 95% CI 1.390 – 2.275, p < 0.001). Discussion:
Obesity is on the rise in industrialized nations in epidemic
proportions. In order to address obesity co-morbidities, like
diabetes and cardiovascular disease, new research is necessary to understand obesity causality. This paper identifies
significant correlations between childhood abuse and
obesity and also confirms the findings of previous studies.
However, further research looking at potential biomarkers is
required to better understand this relationship and to
determine preventative mechanisms as well as improve
treatment guidelines of this serious health threat.
1. WHO Reports
2. Mathers CD, Loncar D. Projections of global mortality and burden of
disease from 2002 to 2030. PLoS Med 2006 3: e442.
3. Sorel, E. (Ed.). (2012). 21st Century Global Mental Health. Jones &
Bartlett Publishers.
P3-27
PRESCRIBING VARENICLINE IN GROUPS
Lead Author: Karen Rice, M.D.
SUMMARY: Background: Although tobacco smoking among
adults has declined by 55% in the United States since 1965,
smoking prevalence among adults with serious mental
illness (SMI) remains high. Six million of the 11.4 million
adults (53%) with serious mental illness smoke tobacco, and
individuals with a mental illness are twice as likely to smoke
as those without a psychiatric diagnosis. Varenicline, a
nicotine receptor partial agonist, is approved by the U.S.
Food and Drug Administration (FDA) for use in smoking
cessation. Rates of smoking cessation with varenicline are
generally two to three times greater than in unassisted quit
attempts. In 2009, the FDA issued a black box warning for
varenicline regarding neuropsychiatric events and possible
suicide, which largely precluded the use of this medication in
individuals with SMI. However, a 2013 re-analysis of this
data found no evidence that varenicline was associated with
such adverse events. As a result, efforts to engage this patient
population are now intensifying. Objectives: The concept of
psychotropic medication groups as a way to reach more
patients in settings where there is a shortage of providers is
not new, and the use of such groups for pharmacological
treatment of substance dependence is gaining popularity.
This is the first report on using group prescribing to address
nicotine dependence. Methods: In a New York State
Personalized Recovery Oriented Services (PROS) program,
patients with nicotine dependence were identified. Patients
were then assessed for their stage of change in regards to
smoking cessation. Groups for each stage of change were
developed, and patients were matched accordingly. Patients
in the preparation and active stages of change were assigned
to a physician-led group utilizing pharmacological aids for
smoking cessation. Groups were held weekly. At the
beginning of each group, participants reported on their
smoking cessation goals, successes, and challenges. Through
this check-in process, topics for therapeutic discussion,
patient education, and peer support were identified. At the
conclusion of each group, patients were provided with
varenicline prescriptions or care with outside prescribers
was coordinated. Outcomes: Data on varenicline use and
quit rates of group participants will be presented. Patient
reports of additional benefits from group counseling,
education, and peer support will be noted. Discussion: This
poster will report on the utilization and efficacy of
varenicline treatment in a group format in a PROS program.
Initial results suggest that prescribing varenicline for
P3-26
CAREER LEADERSHIP AND MENTORSHIPS (CLM)
GLOBAL MENTAL HEALTH INITIATIVES AT WASHINGTON
PSYCHIATRIC SOCIETY
Lead Author: Sajid Baig, M.D.
Co-Author(s): S. Baig, M. Concepcion, M. Thapa1, V. Slootsky,
L. Zhang, C. Dunlap, E. Sorel
SUMMARY: Background: According to WHO, neuropsychiatric conditions account for 14 % of the global burden
of disease. (1,2). Depression and Substance abuse are
amonst the top 10 causes of disabilities (1). Depression is
estimated to be among 3 leading causes of global burden of
disease by the year 2030 in the world, as well as 2nd highest
burden measured by Disability Adjusted Life Year (DALY)
(1,2,3). Mental illness isn't a localized phenomenon. Leaders
in the field conceptualized that it should be addressed
globally. Various initiatives of GMH have been carried out
successfully around the world. This abstract reviews various
activities of this innovative initiative of GMH by DCAPA's
CLM. Methods: Review of literature on Global Mental Health
in peer reviewed journals, popular journals and media.
Review of the events, workshops, activities carried out by
CLM on GMH. Results: CLM's GMH initiative included
various presentations by leaders in the field intended to
educate psychiatry residents and early career psychiatrists in
GMH and to raise awareness of its relevance in the field.
Research and presentations by resident physicians have
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AMERICAN PSYCHIATRIC ASSOCIATION
pertinent for efficient use of finite fiscal resources. Cost
effectiveness analysis is a commonly used health economic
evaluation. It compares the costs and effectiveness of
different treatments. In this poster presentation, we review
the basics of cost effectiveness analysis. We will then discuss
the current evidence on the cost effectiveness of atypical
antipsychotics in various phases of bipolar disorder and
methodological limitations of using this cost effectiveness
analysis. We will follow this with a critical appraise of
available literature and evaluate their generalizability to the
Health Care in the United States.
References
nicotine dependence in a group setting is an effective and
efficient way to focus more clinical attention on smoking
cessation and reach a larger number of patients. Successes,
challenges, and barriers to the model will also be identified.
P3-28
FACING THE TRUTH ABOUT SOCIAL MEDIA;
PSYCHOPATHOLOGY AMONG SOCIAL MEDIA USERS
Lead Author: Adekola Alao
Co-Author(s): Blatchford, Theresa MD; Mattar Mirabelle MD;
Alao, Adekola MD
SUMMARY: Introduction With the increased access to
technology, people have experienced an increase in certain
skills as well as social benefits, but has led to the
development of associated psychopathology. There is a well
documented association of internet use with psychopathology, such as addiction, insomnia, psychosis and
suicide. In this report we present data of reported cases and
studies about psychopathology associated with social media
use. Method A Medline /pub med search using the key
words, social media, face book, suicide, depression, psychopathology, insomnia, psychosis, mental health, mental
illness was searched. Articles retrieved were analyzed and the
data presented in an easy to read table and charts. Results
Internet based therapy and use: There is preliminary
evidence that online interventions can improve positive
psychotic symptoms, hospital admissions, socialization,
social connectedness, and depression and medication
adherence. Mental health providers are divided as the ethics
and utility of using internet technology in practice.
Depression: Using an app called Emotion Diary; researchers
found that people who are more depressed read more tips
and facts about depression. Also people who used facebook
more often had a greater decrease in their life satisfaction
levels. Suicide: Social media has been found to affect some
by spreading suicidal thoughts and acts; however it has also
been able to assist at risk individuals. There was a strong
correlation between state derived suicide related tweets and
suicide rates, which could be very important for prevention.
Conclusion The internet and social media are useful tools
but has been associated with certain psychopathology. More
research is needed to identify the positive and negatives
effect of social media.
Parker G1, McCraw S, Hadzi-Pavlovic D, Fletcher K. Costs of the principal
mood disorders: a study of comparative direct and indirect costs
incurred by those with bipolar I, bipolar II and unipolar disorders. J
Affect Disord. 2013 Jul;149(1-3):46-55.
Pillarella J1, Higashi A, Alexander GC, Conti R. Trends in use of secondgeneration antipsychotics for treatment of bipolar disorder in the United
States, 1998-2009. Psychiatr Serv. 2012 Jan;63(1):83-6.
Robinson R. Cost-effectiveness analysis. BMJ1993;307(6907):793-5.
P3-30
DIOGENES SYNDROME
Lead Author: syed E Maududi, M.D.
Co-Author(s): Dr. S. Maududi MD, Dr. Atifa Nadeem MD,
Stavan Patel MS4, Dr. Hossain MD
SUMMARY: Introduction: Diogenes syndrome (DS) (1), also
known as senile squalor syndrome, is a disorder characterized by extreme self-neglect, domestic squalor, social
withdrawal, apathy, compulsive hoarding of garbage, and
lack of shame. These patients display symptoms of catatonia.
Most patients have been observed to come from homes with
poor conditions, which have faced poverty for a long period
of time. The severe self-neglect usually results in physical
collapse or mental breakdown. Secondary DS is related to
mental disorders. Most individuals who suffer from the
syndrome are not recognized until they fall into this stage of
catastrophe, due to their predisposition to refuse help from
others. Patients diagnosed with Diogenes syndrome display
symptoms of assertiveness, stubbornness, feeling of distrust
for others, irregular mood swings, emotional instability and
deformed insight of reality. When it comes to treatment of
such patients suffering from this disorder there are many
approaches to improve the patient's condition. Day care
services have often been successful with maturing the
patient's physical and emotional condition, as well as aiding
them with socialization. Treatment is aimed towards the
underlying condition; neuroleptic agents, SSRI may help.
New studies appear to suggest that the particular concomitant cognitive and emotional disturbances associated with
hoarding respond to cognitive behavioral therapy. In some
cases patients have to approve to attain help, as they cannot
manage to look after themselves. Hospitals or nursing homes
are often suggested to be the best treatment under these
conditions. When under care, the treatment plan for the
patient should be in a way in which they can learn to trust
the health care professionals. In order to do this, the patients
should be limited in the number of visitors they are allowed,
and be restricted to 1 nurse or social worker.(5) Some
patients have also shown significant improvement to
psychotherapy, while others respond better to behavioral
treatment or terminal care. Method: To understand the
behavioral pattern, underlying cause and the possible course
of treatment of patients suffering from DS, a case study is
done supported by articles from different journals. Objective:
Diogenes syndrome is a perplexing psychiatric illness, as the
P3-29
COST EFFECTIVENESS OF ATYPICAL ANTIPSYCHOTICS IN
BIPOLAR DISORDER: A LITERATURE REVIEW
Lead Author: Venkata Bharadwaj Kolli, M.B.B.S.
Co-Author(s): Vishal Madaan; Durga Prasad Bestha
SUMMARY: Bipolar disorder afflicts up to 3% of the general
population. Disabling nature of the illness, younger age of
onset and chronic relapsing remitting course result in a
significant economic burden. A recent economic analysis
showed a mean life time cost of $160,671 for a Bipolar
disorder type 1 patient and $94,401 for Bipolar disorder II
patient. The armamentarium of bipolar treatments has
expanded with the advent of atypical antipsychotics. They
are used to treat manic, hypomanic, mixed and depressive
phases of bipolar disorder. They have utility in maintenance
treatment too. Atypical antipsychotics are relatively expensive and their use is increasing in bipolar disorder. In a study
of psychotropic prescription for adults, atypical antipsychotics were prescribed in 18% of visits in outpatients
with Bipolar disorder in 1998 and this increased to 49% by
2009. Studying their pharmaco-economic implications is
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
outcomes by create collaborative and integrated care for a
patient's mental and dental health. Discussion: Xerostomia,
or dry mouth, is a common side effect of numerous
psychiatric medications, including SSRIs, TCAs, MAOIs,
haloperidol, Risperdone, Lithium, and methylphenidate
(Griffiths et al, 2000). Xerostomia has been linked to higher
amounts of plaque buildup, peridontal disease, and
increased instances of oral colonization by candidiasis and
lactobacillus. A study by Eltas et al in 2013 demonstrated
higher rates of dental disease in schizophrenic patients
receiving medications that cause xerostomia compared to
schizophrenic patients on medications that cause sialorrhea,
or excessive salivation. If xerostomia due to psychiatric
medications is a contributing factor to dental disease in
psychiatric populations, what should be done to counteract
these effects? A study conducted in Israeli Psychiatric
Hospitals by Ponizovsky et al. (2009) demonstrated that
requiring psychiatric hospitals to provide regular dental care
to inpatients resulted in lower rates of DMFT compared to
off site dental treatment. This difference could be attributed
to the fact that inpatient dental treatment resulted in higher
compliance rates and care by dental professionals
accustomed to working with the mentally ill. In terms of
treatments that specifically address xerostomia, this been
studied more extensively in populations with Sjogren
syndrome. Two treatment modalities that may be applicable
in psychiatric patients include saliva
etiology still remains a mystery and the patient not believing
in healthcare professionals, making the diagnosis and
management very hard. On the other hand some patients
who are helped in hospitals or nursing homes may often
slide back into relapse or may also expire. Our study aims
towards proper understanding of the disorder and outlining
the possible tactics in approaching and caring/ treating such
patients.
P3-31
A RETROSPECTIVE REPORT OF KETAMINE FOR
TREATMENT OF DEPRESSION, IN THE OUTPATIENT
CLINIC SETTING
Lead Author: Wesley Ryan, M.D.
Co-Author(s): Cole Marta, M.D., Ralph Koek, M.D., Terrence
Early, M.D.
SUMMARY: In the mental health community, depression
continues to be a common and disabling condition that can
be a challenge to adequately treat. Inadequate and slow
response, and lack of remission are common barriers to
effective treatment. The current pharmacopoeia available to
clinicians is primarily based on the serotonergic, noradrenergic, and dopaminergic systems, but these treatments are
limited by slow response, typically on the order of several
weeks. Recent studies with the N-methyl-D-aspartate
receptor antagonist ketamine have show rapid and robust
response, on the order of minutes, suggesting a developing
role for the glutamate system in modulation of mood,
especially in patients with a moderate or high suicide risk.
For the time being, use of ketamine has been limited to
research settings, but more and more practioners are
utilizing this agent for treatment refractory cases. Here we
describe several cases from an outpatient psychiatry clinic
practice that has utilized ketamine for treatment of
depression. Various methods of administration (intramuscular, intranasal, sublingual, oral) are reported on in
terms of tolerability and efficacy.
P3-33
AN UNUSUAL CASE OF QUETIAPINE CAUSING TARDIVE
PARKINSONISM: A DIFFERENTIAL TO BE CONSIDERED IN
A PATIENT DEVELOPING PARKINSONIAN FEATURES
Lead Author: Atika Zubera, M.D.
Co-Author(s): Mahreen Raza, M.D., Najeeb Hussain, M.D.
SUMMARY: Background: Dopamine receptor blocking
agents are known to cause Tardive syndromes as described
by Fernandez and Friedman in their review, as a group of
delayed onset involuntary movement disorders which
include Tardive dyskinesia, Tardive dystonia, Tardive akathisia, Tardive myoclonus and Tardive tremor which
included the parkinsonian tremor. It is well documented that
clozapine and quetiapine have the lowest reported incidence
of tardive syndromes. Few cases are reported in the literature
to have progressively deteriorating drug-induced parkinsonism or tardive parkinsonism (TP). We present an unusual
case of tardive parkinsonism caused by prolonged exposure
to quetiapine which is unlikely to cause tardive parkinsonism. Case presentation: A 60 yr old caucasian female with
past psychiatric history of Bipolar disorder type 1, most
recent episode depressed was transferred from another
facility for further management and treatment. Patient
presented with c/o urinary and fecal incontinence, masked
facies and parkinsonian tremor. Patient had developed stage
III sacral decubiti ulcers. As per chart review, patient had h/o
taking mutliple atypical antipsychotic agents which included
quetiapine for prolonged period of time. Patient was
admitted to the surgical floor under psychiatry for management of her sacral decubiti. Patient was started on Lithium
and Bupropion. Patient's antipsychotic medications were
slowly tapered. Patient was also started on Physical therapy.
Patient slowly improved and she was able to ambulate
independently. Patient became more verbal and her sacral
decubiti healed completely. Patient however continued to
remain incontinent of urine and feces and continued to have
the parkinsonian features. Neurological consultation
P3-32
MENTAL AND DENTAL HEALTH: TIME TO LOOK BEYOND
THE RHYME
Lead Author: Atika Zubera, M.D.
Co-Author(s): Mahreen Raza, M.D., Ye-Ming Sun M.D., Eric
Haloday MS III
SUMMARY: Introduction: Anecdotal evidence would support
the claim that poor dentition is frequently found amongst
the chronically mentally ill. A review and meta-analysis by
Kisely et al in 2011 supports this claim, findings that the
chronically mentally ill had significantly higher rates of
dental disease including decayed, missing, and filled teeth
(DMFT) compared to the general population. Like most
health issues, dental health is multifactorial, and therefore
the discrepancy is likely attributable to a multiple of causes.
These may include, but are not limited to the cost of dental
care, lack of insight into dental health problems, poor
personal dental hygiene, poor diet, substance abuse, and
dental phobias. While the aforementioned problems are
considerations that should be addressed, they are not unique
to the psychiatric population. Therefore, we hope to focus on
potential causes of poor dental health that are unique to
psychiatric patients. In particular, we hope to examine the
contribution of psychiatric medication side effects, specifically xerostomia, in dental disease in the chronically
mentally ill. A study of the impact of psychiatric medication
side effects and dental health could help improve patient
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AMERICAN PSYCHIATRIC ASSOCIATION
antipsychotics such as haloperidol are associated with an
increased risk of smoking. There have been consistent
reports of smoking increasing haloperidol plasma clearance,
and decreasing haloperidol plasma concentrations at steady
state with increase in clearance (44%) and decrease in serum
concentrations (upto 70%).We suspect that her dosing of
haloperidol was increasingly metabolized by enzyme induction, she improved on switch to Risperidone which is not
induced by cigarettes.
revealed that patient's parkinsonian features could be due
prolonged exposure to antipsychotics. Patient's medical
records were reviewed which revealed a prolonged exposure
to quetiapine in the past. Discussion: With our case
presentation we emphasize the importance of looking for
this rare and irreversible adverse effect of prolonged use of
quetiapine in patients with chronic psychiatric illnesses.
Although quetiapine is less likely to cause tardive parkinsonism as an adverse effect, patient receiving quetiapine
should be monitored carefully by their treating psychiatrists
with frequent neurological examinations. Further randomized control studies exploring this topic are warranted.
P3-35
RECURRENT STEROID-INDUCED PSYCHOSIS IN THE ICU
Lead Author: Jaimini Chauhan-James MD
Co-Author(s): Elisa N Simon MD, Steven Vargas MD, Raj
Addepalli, MD
SUMMARY: Introduction The role of corticosteroids in
suppressing inflammation in the management of asthma has
been well-established; however, corticosteroids, especially in
doses used for moderate to severe persistent asthma, have
been associated with many neuropsychiatric side effects
including severe agitation and disturbances in mood and
psychosis. We present a case of recurrent psychosis
secondary to systemic corticosteroid use in a patient with
severe, persistent asthma. Case Description Within the span
of three years, this patient was admitted to the ICU at with
severe exacerbated asthma and on three visits the patient
developed psychotic symptoms of paranoid delusions,
auditory and/or visual hallucinations. On the first visit the
patient received a total of 2580 mg of steroids over 8 days
with psychotic symptoms on the 9th day. Two years later; the
patient was admitted again and received a total of 1700 mg of
steroids over 9 days with psychotic symptoms on the 10th
day. The last visit a few weeks later warranted 1145 mg of
steroids and the patient had symptoms two days after
receiving the last dose. Discussion The occurrence of
steroid-induced psychosis has been overestimated in past
studies because patients who developed delirium have often
been labeled as having psychotic symptoms. The most
common psychiatric effects of corticosteroids are symptoms
of mania or hypomania . As high as 5.7% of patients in one
study developed severe psychiatric symptoms who were
given more than 80mgs/day of prednisone. Psychosis and
steroid use is dose-related. In one study, a dose of <40 mgs of
steroids showed lowest incidence of psychosis; doses 40-80
mgs 5% incidence and >80 mg/day with rates of 18.4% . Our
patient received much higher doses than this, at one time
receiving 500mgs/day of intravenous Solumedrol. Management of steroid psychosis includes decreasing the dose of
steroids to <40mgs/day which likely will result in spontaneous resolution of psychotic episodes without any
psychiatric intervention. Many antipsychotics and/or mood
stabilizers have been found to be effective in treating steroidinduced psychosis ; but there are no existing guidelines for
the same. Our patient is likely to suffer another asthma
exacerbation and a strategy to intervene early should be
considered, including close monitoring of symptoms and
steroid dosing with early psychiatric intervention. Conclusion Psychosis is an unfortunate iatrogenic effect of systemic
corticosteroid use and few reports of recurrent cases and no
treatment guidelines exist to address this phenomenon. Risk
factors should be addressed and clinicians should have a
high index of suspicion for developing psychosis for patients
receiving dose of >80mgs/day of prednisone or its
equivalent.
P3-34
THE INTERPLAY BETWEEN SMOKING AND ANTIPSYCHOTICS: AN OFTEN OVERLOOKED CAUSE OF
RELAPSE OF SYMPTOMS
Lead Author: Elisa Simon MD
Co-Author(s): Steven Vargas MD, Raj Addepalli MD, Pronoy
Roy MD,
SUMMARY: Introduction: We present a case of a 59 year old
Hispanic female with schizoaffective disorder who has been
repeatedly admitted to the inpatient psychiatric unit. We
suspect that in this case her relapse within a few days of
discharge, after attaining stabilization of her manic symptoms has been precipitated by cigarette smoking which
causes increases breakdown of Haloperidol by enzyme
induction. Case Description: Ms. T has a diagnosis of schizoaffective disorder and HTN with more than 15 life time
admissions and was initially admitted in July 13 after an
accidental overdose of Lithium and subsequently she was
admitted to the inpatient unit and treated with haloperidol
and Oxcarbazepine. She was stabilized and discharged after
a 4 week stay. Neuropsychological testing had documented
mild cognitive deficits. Subsequently over a period of 5
months- she was readmitted 4 more times with only a week
or 10 days between each admission. Her outpatient services
were upgraded to an Intensive case manager and subsequently referred to court mandated Assisted outpatient
treatment and again after a subsequent discharge upgraded
to an Assertive community treatment program. She was
discharged after the last admission with 100 mg of
Intramuscular Haloperidol decanoate along with supplementation of haloperidol and oxcarbazepine by mouth. After
the last hospitalization she was discharged with complete
resolution of her manic and psychotic symptoms and referral
to a Visiting Nurse Service to ensure compliance with her
medications along with ACT services, 1 week later she was
again readmitted with floridly manic and psychotic
symptoms.On interview, patient insisted that this time she
had been consistent with taking haloperidol. She did
however admit to chain smoking upon discharge. At this
time, there was strong suspicion that her 1.5 pack cigarette
habit had caused a drop in serum haloperidol levels which
led to a relapse of symptoms precipitating her admission of
her chainsmoking.Discussion:The prevalence of smoking is
twofold to threefold higher in patients with schizophrenia
spectrum disorders than in the general population, and of
this population about “88% of patients are current smokers.
Cigarette smoke constituents include polycyclic aromatic
hydrocarbons that induce 3 isoforms of CYP: CYP1A1,
CYP1A2 and possiblyCYP2E1, and some isoforms of UDPglucuronosyltransferase and CYP1A2, which decreases the
blood concentrations of olanzapine and clozapine. Typical
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
families but the role of genetics on depression are not clearly
understood. Research has shown that those whose parents
or siblings suffered from depression are more likely to suffer
from depression as those with no close relative suffering
from the disease. Also, many studies have found some
association between gender and depressive disorders. Often,
studies report that women have a higher prevalence rate for
depression compared to men Objective The objective of this
study is to determine if there is any association between
gender and depression as well as look at the role of genetics
in depression Subjects: 489 chronic pain patients from 10
research sites in the US. 241 with a personal history of
depression and 248 with no personal history of depression
retrieved from answers in the ORT (Opioid Risk tool)
completed by each patient. Females N= 338, Males N=151.
Methods: Subjects were genotyped with the proprietary
Proove Narcotic Risk Genetics Profile using TaqMan SNP
genotyping assays (Life Technologies, Carlsbad, CA). It
consist of a panel of 12 SNPs (DRD1 -48A>G, DRD2 A1 allele,
DRD4 -521C/T, DAT1, COMT Vall58Met, OPRK1 36G >T,
OPRM1 A118G, DBH -1021 C/T, 5-HT2A -1438G/A, 5HTTLPR, Gamma-Aminobutyric Acid (GABRA 6) (1519T>C
GABA(A) alpha 6 gene), and MTHFR C677T). Results:
Females compared to men from a chi square test of
association were more likely to be associated with patient
with a personal history of depression (P=0.015, likelihood
ratio 0.015, Fishers Exact 0.019, OR 1.616). Using a binomial
logistic regression with IBM SPSS, Normal COMT was found
to be more associated with patients with a personal history
of Depression and homozygous mutation of COMT was
more associated with those patients with no personal history
of depression. (P= 0.0048, OR 2.711) Conclusion: This study
suggests that gender plays a role on depression and females
are more likely compared to males to be associated with
depression. In addition, the study suggests that homozygous
or mutation of COMT may have a protective effect on
depression and having a mutation or normal of COMT could
make a difference in genetic susceptibility to depression.
P3-36
TARDIVE DYSKINESIA: UNUSUAL PRESENTATION AFTER
BRIEF EXPOSURE TO ATYPICAL ANTIPSYCHOTICS
Lead Author: Asif Khan, M.D.
Co-Author(s): Pankaj Lamba, M.D., Bakul Parikh, M.D
SUMMARY: Introduction: Tardive dyskinesia (TD) is a
hyperkinetic movement disorder that appears with a delayed
onset after prolonged use of dopamine receptor blocking
agents, especially typical antipsychotics. TD has numerous
clinical manifestations that include chorea, athetosis,
dystonia, akathisia, stereotyped behaviors, and rarely
tremor. TD most commonly manifest as orofacial movements, which are considered prototypical. Here we report a
case of TD selectively involving the lower limbs after a
relatively brief exposure to atypical antipsychotics (ziprasidone, risperidone, olanzapine). Case Report: A 67-year-old
Caucasian female with a long history of mood and anxiety
disorder presented with chief complaints of distressing
movements of the lower limbs. These involuntary movements had developed four to five months back after she
started receiving atypical antipsychotics as mood stabilizers.
She was initially treated with ziprasidone 60 mg titrated to
120 mg which led to development of restlessness. She was
then switched to risperidone titrated to 4 mg which led to the
development of abdominal tics and lower limb movements
after one month of treatment. She was finally switched to
olanzapine titrated to 20 mg and within six days the
movements in the lower limbs further exacerbated. Following this the antipsychotic medications were discontinued.
The patient continued having the symptoms and consulted
our clinic for a second opinion. On first visit, she appeared
depressed and stressed due to her symptoms. The examination was significant for continuous bilateral choreiform
movements of toes, feet and legs. Abnormal Involuntary
Movement Scale (AIMS) was positive for severe movements
in the lower extremities. On global judgment the severity of
the abnormal movements overall was severe with moderate
incapacitation due to abnormal movements and patient's
awareness of abnormal movements was reported as aware,
severe distress. The preliminary diagnosis of TD was
considered. She was started on clonazepam, to which she
showed mild response. The patient was also referred for
neurological evaluation and presence of organic neurological conditions were ruled out. She was referred for
evaluation at the University of Michigan Movement Disorder
Clinic. The Clinic confirmed our initial diagnosis and also
noted the selective involvement in the lower limbs.
Discussion: This case illustrates the potential of developing
TD with relative involvement of lower limbs, sparing the
orofacial region and upper limbs. TD in this case developed
after three months of first exposure to the atypical
antipsychotic medications which are considered to have
lower risk compared to the typical antipsychotics. Patients
should be informed about the potential of developing TD
with relatively lower risk, newer, atypical antipsychotics.
P3-38
ADHD AND GENETICS: STUDY ON THE ROLE OF
GENETICS ON ADHD AND RISK OF OPIOID ADDICTION
Lead Author: Tobore Onojighofia, M.D., M.P.H.
Co-Author(s): B. Meshkin, B. Akindele MD, D. Schwarz MD, J.
Hubbard, S. Chang PhD, Derrick Holman MD, Juetong Chen,
T. Onojighofia MD
SUMMARY: Background: Several studies have shown that
attention-deficit/hyperactivity disorder (ADHD) represents a
significant risk factor for the onset and development of
addiction. A great deal of research have also been carried out
to determine the role of genetics in attention deficit
hyperactivity disorder Objective The objective of this study is
to determine the role of genetics in ADHD. Also, it aims to
determine if any association exist between males and
females with ADHD and risk of narcotic misuse or abuse.
Subjects: 91 chronic pain patients across 5 clinical sites, 51
diagnosed with Attention deficit disorder with hyperactivity
(ADHD ICD code series 314.01) and 40 with no diagnosis of
ADHD. Females N= 49, Males N=42. Methods: Subjects were
genotyped with the proprietary Proove Narcotic Risk
Genetics Profile using TaqMan SNP genotyping assays (Life
Technologies, Carlsbad, CA). It consist of a panel of 12
(Single Nucleotide Polymorphism) SNPs (DRD1 -48A>G,
DRD2 A1 allele, DRD4 -521C/T, DAT1, COMT Vall58Met,
OPRK1 36G >T, OPRM1 A118G, DBH -1021 C/T, 5-HT2A -
P3-37
ROLE OF GENETICS IN DEPRESSION: STUDY ON THE
INFLUENCES OF GENDER AND GENETICS IN
DEPRESSION
Lead Author: Tobore Onojighofia, M.D., M.P.H.
Co-Author(s): B. Meshkin, B. Akindele MD, D. Schwarz MD, T.
Onojighofia MD, John Hubbard, Derrick Holman MD
SUMMARY: Background: Depressive disorders are commonly occurring psychiatric conditions that tend to run in
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AMERICAN PSYCHIATRIC ASSOCIATION
changes will be presented, and areas of the PHQ-9 which
seem particularly vulnerable to misinterpretation will be
discussed. Conclusions: Our small screening survey indicates
that the PHQ-9 may be reliable, but our study also highlights
the disparity in the understanding and layout of the PHQ-9
among a Caribbean and African-American patient population. Many of the patients may have inappropriately read
and misunderstood the survey, and many indicate never
being surveyed prior to the study. A larger study would more
accurately assess the reliability among this patient
population, but this may also indicate that greater strides in
screening and creating an easier-to-understand, userfriendly layout may be conducive to surveying a minority
community in a primary care setting.
1438G/A, 5-HTTLPR, Gamma-Aminobutyric Acid (GABRA 6)
(1519T>C GABA(A) alpha 6 gene), and MTHFR C677T). A
scoring algorithm, the Narcotic Risk Index (NRI) score (<19 is
low risk for opioid abuse or misuse and 19 and greater is high
risk for opioid abuse or misuse) was also calculated to
determine elevated risk of opioid misuse or abuse. Results:
Females compared to men with Attention deficit disorder
with hyperactivity (ADHD) from a chi square test of
association were more likely to be associated with a greater
risk of prescription opioid misuse or abuse (NRI of greater
than or equal to 19) p=0.040, OR= 1.490, Likelihood ratio
0.038, Fishers Exact 0.037. An independent sample T- test
shows a statistically significant difference in the narcotic risk
index score between males and females (F = 2.391, Sig, 0.128,
T= 2.097, DF= 49, Sig= 0.044). Average Narcotic Risk Index for
males was 17.8(<19 low risk for opioid misuse or abuse) and
Females 19.2(>19 High risk for Opioid misuse or abuse). A
chi square test of association for all 91 patients shows an
association between MTHFR, DRD2 and ADHD. (MTHFR P=
0.005, Fishers Exact 0.004, DRD2 P= 0.002) Conclusion: This
study suggests that genes play a role in the risk of ADHD.
MTHFR and DRD2 show an association with ADHD and may
play a role in the risk of having ADHD. From the study,
females with ADHD have a higher likelihood of opioid
misuse or abuse because a Narcotic Risk Index (NRI) of
greater than or equal to 19 is more associated with females
with Attention deficit disorder with hyperactivity (ADHD)
compared to males with ADHD. Findings in this study could
help improve understanding of the role of genes in ADHD
and the role of gender in narcotic misuse or abuse risk
among chronic pain patients with ADHD.
P3-40
GENETICS AND MENTAL HEALTH DISORDERS: STUDY
ON THE ROLE OF GENETICS IN PATIENTS WITH A
PERSONAL HISTORY OF MENTAL HEALTH DISORDERS
Lead Author: Bilikis Akindele, M.D.
Co-Author(s): B. Akindele MD, B. Meshkin, D. Schwarz MD, J.
Hubbard, S. Chang PhD, T. Onojighofia MD, Derrick
Holman, Juetong Chen
SUMMARY: Background: Many mental disorders are
believed to result from the complex interplay of multiple
genes with environmental factors. Several family studies with
identical twins have provided evidence of genetic contributions to many mental health disorders like depression,
bipolar disorder, schizophrenia and autism. However, the
exact role of genetics and the genes that influences
predisposition to mental disorders are not clearly understood. Objective The objective of this study is to determine if
there is any association between certain genes and mental
health disorders. Subjects: 5920 chronic pain patients from
40 clinical research sites in the US. 907 had a personal
history of mental health disorder derived from answers from
the ORT (Opioid risk tool) questionnaire. Average age 52.
Methods: Subjects were genotyped with the proprietary
Proove Narcotic Risk Genetics Profile using TaqMan SNP
genotyping assays (Life Technologies, Carlsbad, CA). A panel
of 12 SNPs (DRD1 -48A>G, DRD2 A1 allele, DRD4 -521C/T,
DAT1, COMT Vall58Met, OPRK1 36G >T, OPRM1 A118G,
DBH -1021 C/T, 5-HT2A -1438G/A, 5-HTTLPR, GammaAminobutyric Acid (GABRA 6) (1519T>C GABA(A) alpha 6
gene), and MTHFR C677T) Results: A chi square test using
JMP showed age had an association with patients with a
personal history of mental health disorders (P=0.001), Agegroup 40 to 64 were more associated with patients with a
personal history of mental disorders compared to other age
groups. DBH of all 12 SNPs showed an association with
patients with a personal history of mental health disorders.
Further analysis using a binomial logistic regression showed
that DBH homozygous mutation was more associated with
patients with a personal history of mental health disorders
while Normal and heterozygous DBH for those with no
personal history of mental health disorders.(Normal OR
1.579, p <0.0001, Heterozygous OR 1.3618, p 0.0047)
Conclusion: This study suggests that age plays a role in
mental health disorders and age group 40-64 are more likely
to be associated with mental health disorders. In addition,
the study suggests that having a homozygous mutation for
DBH may influences genetic susceptibility to mental health
disorders.
P3-39
THE RELIABILITY OF THE PHQ-9 AMONG THE CARIBBEAN AND AFRICAN AMERICAN COMMUNITY: A SMALL
SURVEY AT A FAMILY HEALTH CENTER IN EAST
FLATBUSH, NY
Lead Author: Erik Copeli, B.S.
Co-Author(s): Dr. Ramotse Saunders, Dr. Stephen Goldfinger
SUMMARY: Objective: To evaluate the reliability of the PHQ9 depression survey in a Caribbean and African American
population through their understanding of the survey's
language and layout. Study Design: PHQ-9s are routinely
collected from patients at a family health center during their
regularly scheduled appointments. In addition to their
independent answers, the researcher (a medical student on
rotation there) went over each question with them, recording
any differences after explaining some potentially misunderstood questions. Methods: A total of 31 patients were
approached during their regular screening and family
medicine check-up at the Lefferts Family Health Center in
Brooklyn, NY in and given a PHQ-9 to fill out independently.
When completed, the patients were subsequently approached by an interviewer and asked to conduct another PHQ-9
but with verbal guidance, explanations and elaboration of
the PHQ-9 surveys by the interviewer. The differences in
scores and answers on the exam were compared between the
first self-survey and the subsequent guided survey. Results:
Twenty-six patients who agreed to and completed the survey
showed minimal change in their scoring of the survey. There
were, however, some areas of the survey where changes were
made in roughly half of the patients. The impact of these
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
statistical principles, as well as principles and design of
clinical trials. 3- Designated research month and individualized research project: one month that is built in the PGY-2
year. During this month, the residents are involved in
reviewing a manuscript under the mentorship of the Chair
and the Chief resident for research and academics. 4- Group
course and individual 'practicum' on reviewing manuscripts:
this course was started this year and was for the 2nd year
residents. Outcome of the program: There is a substantial
contribution of residents in research and the resultant
increase in presentations and poster presentations at
regional, national and international meetings. There are 2
residents who are simultaneously pursuing PhD tracks with
the residency. Over the past 5 years, over 80% of our
residents have either gone on to post-graduate fellowships or
joined the faculties of major teaching universities
Conclusions: Focusing educational structure and resources
on developing academic interests and research skills in a
residency training program can dramatically enhance
trainees' knowledge, productivity and career paths. Designating a chief resident with responsibility to oversee these
endeavors, and securing Chair and faculty support are
critical components. Although no model will (or should)
result in all trainees pursuing academic careers, we have
found that an extraordinarily high percent of our trainees go
on to pursue fellowships and academic faculty positions.
Although no causal relationship can be proven, our findings
represent a substantial increase over prior years' graduates.
P3-41
CBT FOR PSYCHOSIS: A CASE PRESENTATION
Lead Author: Yihou Zhou, B.A.
Co-Author(s): Michael Garrett, MD; Lin-Lin Wang, MD
Candidate; Ramotse Saunders, MD
SUMMARY: Cognitive Behavioral Therapy is a psychological
treatment with a clear efficacious role in the treatment of
depression and anxiety. Despite mounting interest in its
possible role in the treatment of psychotic symptoms,
training in this approach and clear examples of its
applications are hard to come by outside of select academic
centers. The following is a detailed case report of a 50-yearold woman with auditory hallucinations who underwent
CBT directed toward the etiology, tone, and validity of her
voice hearing experience. Along with concurrent psychopharmacological treatment, the use the CBT after 8 sessions
resulted in decreased intensity of voices, increased insight
regarding the experience, and increased subjective sense of
control. This case offers an example of the role of CBT in
psychotic patients with adequate reality testing as an adjunct
to psychopharmacology.
P3-42
RISK FACTORS FOR PSYCHIATRIC HOSPITAL ADMISSION
FOR PARTICIPANTS IN CALIFORNIA'S FULL-SERVICE
PARTNERSHIP PROGRAM
Lead Author: Michael J Penkunas, Ph.D.
SUMMARY: This study investigated the demographic and
clinical predictors of psychiatric hospitalization during the
first two years of treatment for adults participating in the
full-service partnership (FSP) program, based on Assertive
Community Treatment, in a large county in northern
California. Clinical and demographic characteristics, data on
prior hospitalizations, length of enrollment, and living situation for 328 FSP participants were collected from the
county's internal billing system and the California Department of Health Care Services. In univariate models, the
probability of hospitalization varied by diagnosis, age, and
hospitalization history. In the multivariate model, younger
age and frequent hospitalization prior to enrollment
predicted hospitalization during enrollment. Findings
support prior research on hospital recidivism and may be
beneficial in refining future strategies for meeting the needs
of adults with serious mental illness.
P3-44
GLOBAL MENTAL HEALTH CURRICULUM
Lead Author: Alicia Barnes, D.O., M.P.H.
SUMMARY: There is an increase interest in Global Mental
Health in psychiatric education along with growing career
opportunities, with international non-profit foundations,
academia and local immigrant populations. A Global mental
health curriculum provides a tremendous opportunity to
learn about international health issues, intercultural exploration, and cultural humility. This poster is a description of
Cooper University Hospital's pilot curriculum. The rational
for a Global Mental Health lecture series and electives is to
give insight into cultural considerations working with immigrant populations and comparing systems of delivering
mental health across the world. Second, it has been found to
increase interest in serving underserved populations. Finally
it aids as a recruitment tool for residency programs and to
increase scholarly activity. At Cooper University Hospital
Psychiatry Department a global mental health curriculum
was established July 2013. The curriculum consists of six,
two-hour lecture series, on mental health in different
countries. The lecture series is entitled Psychiatry on a World
Stage and consists of interactive presentations led by faculty
with international mental health experience. In the first year,
Cuba, Nigeria, Russia, Philippines, Liberia, and Dominican
Republic were presented. The series also included a seminar
by the President of the World Psychiatric Association about
the field of Global Mental Health and future challenges.
Medical students, residents, and faculty attended the series,
with an average attendance of 20 people per session. The
curriculum created networking opportunities and collaborations between residents and medical students with
common interests. A Curriculum in Global Mental Health is
a method to increase learning about various systems of care.
It has created discussions and interest in examining mental
health systems internationally. The lecture series has served
P3-43
PROMOTING SCHOLARLY ACTIVITY IN JUNIOR
RESIDENTS: AN INTERVENTION
Lead Author: Mohamed Amr Sherif, M.D., M.Sc.
Co-Author(s): Ellen J. Berkowitz, Stephen M. Goldfinger
SUMMARY: Introduction: Providing an environment which
supports a spirit of academic inquiry, imparts competencies
in critical thinking and scientific methodology, and promotes residents' productivity as scholars is an area of
training that is frequently overlooked or given only passing
attention. The Department of Psychiatry and Behavioral
Sciences at SUNY Downstate instituted a multifaceted model
designed to address these issues with minimal expenses
while exposing residents to several components of academic
scholarship. Components of the program: 1- Chief resident
for research & academics (CRRA): who oversights the
research activities of the residents, as well as the components of the program. 2- Research methodology course:
taught by a number of faculty members, and covers an
introduction to research methodology, introduction to
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AMERICAN PSYCHIATRIC ASSOCIATION
P3-46
THE UTILITY OF ELECTROCONVULSIVE THERAPY IN
INPATIENT SETTINGS: ADDRESSING SOME OF THE
CHALLENGES
Lead Author: Arman Fesharaki, M.D.
Co-Author(s): Thulasiram Janardhanan, M.D.
SUMMARY: Background: ECT was first introduced in clinical
practice in 1934, and it remains the most effective treatment
not only for major depressive disorder, but also for
delusional depression, bipolar disorder, schizophrenia,
catatonia, neuroleptic malignant syndrome, and parkinsonism. In up to 85% of otherwise treatment resistant cases,
ECT is an effective treatment. Despite the aforementioned
efficacy, there are practical and logistic challenges that have
thus far limited its utility in various clinical settings. The past
decades have witnessed a decline in usage of ECT, due to a
multitude of reasons, including the advent of newer antidepressants with relatively fewer side effects, more effective
screening methods and hence earlier treatment of patients
suffering from major depression, as well as more closely
monitored outpatient follow up. Objectives: To identify and
address some of the current challenges in regards to ECT
utilization in various inpatient settings. Results: Based on
prior findings, various challenges that face a wider use of this
effective therapeutic regimen, are worthy of mentioning.
These include a lack of a standardized inpatient ECT
protocol and practice guidelines, a perpetuating public
stigma in regards to the usage of ECT and its potential side
effects such as anterograde amnesia, the logistic challenges
of using ECT as a surgical procedure in an inpatient setting,
as well as limited clinical as well as financial incentives for
the use of this modality. In order to address some of these
challenges, wider education both in the professional mental
health as well as public settings in regards to both risks and
benefits of the use of ECT in an inpatient setting, is of
paramount importance (Fink M., 2001). These benefits have
not only been demonstrated in terms of superior outcomes,
on a clinical in addition to biological basis, with recent
research demonstrating increase in neurogenesis post ECT
(Perera et al., 2007). Conclusion: ECT remains a highly
efficacious, underutilized treatment modality, which,
through increased education, funding and treatment
centers, could yield superior comes in the thousands of
treatment resistant individuals who suffer from MDD and
other disorders.
as an avenue to engage residents in the discussion of the
impact of culture on psychiatric illness. Future directions of
the curriculum are to advance to a one-month international
elective for residents to have an immersion experience.
P3-45
MOXIFLOXACIN INDUCED PSYCHOSIS: A CASE REPORT
STUDY
Lead Author: Arman Fesharaki, M.D.
Co-Author(s): Dr. Ramotse Saunders
SUMMARY: Background: Fluoroquinolones, a broad spectrum antibiotic frequently used in medical units for upper
respiratory infections and urinary tract infections, have been
demonstrated to cause drug induced mental status changes
(Farrington et al. 1995). These changes, though reported to
be less than 0.1%, could potentially manifest themselves as
delusional thought process and hallucinations (Blondeau et
al. 1999, Perry et al. 1999). One theory proposed to explain
this rare phenomena is the blockage of GABA receptorbinding, in turn causing secondary excitatory changes as per
measured EEG recordings (Segev et al. 1988). Discussion:
The reported patient is a 91 year old woman with prior
medical history of chronic obstructive pulmonary disease
(COPD), hypertension, hyperlipidemia, coronary artery
disease, peripheral artery disease and without prior
psychiatric history. The patient was admitted to the inpatient
medical unit for management of COPD exacerbation, for
which she was started on oxygen therapy, prednisone 40mg
tab PO daily (the patient was on long term prednisone
regimen), montelukast 10mg tab PO every evening at 7pm, as
well as Moxifloxacin 400mg tab PO daily. On the following
evening after her admission, the patient became acutely
agitated, displaying paranoid delusions comprised of patient
believing that the inpatient nurses and staff members were
trying to steal her belonging and kill her along with another
neighboring patient. Despite multiple behavioral interventions from the inpatient staff members, the patient remained
acutely agitated. The patient also refused all PO medications,
and due to continuing psychotic symptoms, haloperidol
2.5mg IM was administered. The patient responded favorably to this regimen, and was seen the following day by the
Consultation Liaison (CL) psychiatric team. The patient
appeared markedly less agitated, and was able to recount the
previous night's episode. The patient also remained
paranoid, convinced that the night time staff was still
planning to harm her, and she requested immediate
discharge despite the necessity of continuing medical care.
After reviewing patient's chart, it was verified that this was
the first psychotic episode. Given that this was the patient's
first exposure to Moxifloxacin, and in light of prior clinical
reports regarding the possible psychiatric manifestations
regarding various fluoroquinolones, the CL team recommended discontinuation of this regimen. Her psychosis
immediately resolved upon discontinuation of the moxifloxacin and there was no evidence of any residual psychotic
symptoms as per her primary and the CL team. Conclusions:
Given prior reports of floroquinolone induced mental status
changes and with rare but possible psychiatric manifestations, due clinical diligence is advised specially in the
elderly population with co-morbid medical conditions. A
comprehensive review of patient's medications, in the
context of medical and psychiatric history, is clearly
indicated.
P3-47
INSIGHT IN OLDER ADULTS WITH SCHIZOPHRENIA
Lead Author: Anup Mani, D.O.
Co-Author(s): Carl I. Cohen MD, Judy Burke, Ifeyani Izeiduno
MD
SUMMARY: Objective: Little is known about the stability,
related factors, and role of insight in older persons with
schizophrenia. This study examines insight and associated
variables over time in this population. Methods: 250 New
York City residents aged 55 and older with schizophrenia
spectrum disorders; all patients developed the disorder prior
to age 45. Data on 104 subjects followed for a mean time of
52 months are presented; there were no significant differences in demographic factors or insight at baseline between
those in the follow-up group and those who did not
complete the study. Mean age of the follow-up group was 61
years old; 55% were male, and 55% were white. There has
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
adults. Hearing impairment and social isolations have been
suggested as predisposing factors. Auditory hallucinations
have consistently been associated with traumatic experiences during childhood. As per our knowledge, this is the
first case of MH which is found to be associated with
childhood abuse.
been considerable debate as to what constitutes insight, and
multi-dimensional scales have shown very high correlations
with one item measures suggesting that a dichotomous
variable of insight may be equally valid as a complex
measures. Therefore, in this study, "insight" was considered
present if persons acknowledged that they have a mental
illness. This subjective measure of insight correlated highly
with the rater assessment on the PANSS Insight and
Judgment item (r=.60, p<.001). Results: 65% of persons had
insight at baseline (T1) and at follow-up (T2), 16% had no
insight at T1 and T2, and 25% fluctuated between the two
categories. There was no significant difference in prevalence
of insight at T1 (78%) and T2 (69%). Ten variables identified
in the literature as being associated with or component of
insight were examined. In bivariate analysis 8 of the variables
were significantly insight: baseline insight, younger age,
lower PANSS conceptual organization scores, lower PANSS
blunted affect scores, higher quality of life, higher concepttualization scores on the Dementia Rating Scale, higher
levels of depression, the influence of clinicians, and the
impact of subject's beliefs about the illness. Using logistic
regression analysis, four T1 predictors retained significance
as predictors of insight at T2: insight at baseline (OR=11.53),
younger age (OR=0.84), lower levels of conceptual disorganization (OR=.55), and lower levels of blunted affect
(OR=0.36). Conclusions: The findings suggest that there is
fluidity in levels of insight over time, although about twothirds of subjects maintained insight over both periods.
Many factors thought to be associated with or components
of insight were predictors of insight at T2, although four
variables did not retain significance in multivariable
analysis. With respect to causal models, our data indicates
that certain features of positive and negative symptoms
affect perception of insight, whereas those with insight are
more apt to develop closer personal relationships and use
more clinical services. These findings suggest potential
points of interventions in the care of older adults with
schizophrenia.
P3-49
EMOTION RECOGNITION DEFICIT AND EMOTIONAL
RESPONSES TO AFFECTIVE PICTURES IN PATIENTS WITH
SINGEL RIGHT HEMISPHERE DAMAGE
Lead Author: Sonia Alvarez-Fernandez, M.Sc.
Co-Author(s): Maria Serrano-Villar, M.Sc., Patricia Simal,
M.D., Alvaro Ruiz-Rodriguez, M.Sc., Jose A. Suarez-Meneses,
M.D., Samuel Romero, M.D., Guillermo Lahera-Forteza,
M.D., Ph.D.
SUMMARY: Right hemisphere damage (RHD) has been
linked to Facial Emotion Recognition (FER) deficit, though
studies present limitations. Emotional processing findings
show no differences between patients and controls in
affective valence ratings of emotional pictures (SanchezNavarro, 2005). Others show a significant difference in
unpleasant pictures and a distinct skin conductance
response (SCR) (De Sousa, 2010). Few studies about single
RHD have been published. Objectives: Comparing FER skills,
and SCR and valence ratings during emotional pictures
processing, in single RHD patients to a control group. Aims:
Identifying FER patterns and analyzing differences according
to type of emotion. Examining emotional processing, both
physiologically and subjectively. Checking a possible relation
between FER and emotional processing. Method: 46 patients
with a single RHD (mean age 68.93;SD=12.62. 52% males),
treated in Hospital Clinico S. Carlos Stroke Unit (Spain),
were assessed after 3-12 months from stroke. 46 control
subjects (67.28;SD=18.29. 50% males) were assessed.
Participants were evaluated in sociodemographic and
clinical variables through a clinical interview, as well as the
Mini-mental State Examination and Hamilton Depression
Rating Scale. 59 pictures from Pictures of Facial Affect
(POFA) collection (Ekman, 1993) were shown to the sample,
which identified them according to the type of emotion (i.e.
happiness, fear, surprise, sadness, disgust, anger). 54
pictures from International Affective Picture System (IAPS)
(Lang, 1999) were shown to the subjects, while SCR was
measured. As well, the sample rated the valence of each
picture among 3 categories (pleasant, neutral, unpleasant) in
a 1-9 scores Likert scale. Results: Both samples showed
significant differences in FER (T=-2.751;p=0.007). Lowest
performance was obtained in identifying fear (mean correct
answers 0.45;SD=0.25) and anger (0.48;SD=0.30) in total
sample. RHD patients showed a deficit in FER skill compared
to controls. Significant differences were found in recognizing
anger (T=-2.043;p=0.044), disgust (T=-2.059;p=.042), happiness (T=-2.371;p=0.020), and sadness (T=-2.633;p=0.010). As
some previous research, no differences were found in
affective valence rating between RHD patients and control
subjects. Both samples rated unpleasant pictures as less
pleasant than neutral ones, and pleasant pictures as more
pleasant than neutral ones. As well, neither SCR significant
differences were found between both groups. Conclusions:
Results suggest a relationship between RH and FER. Therefore, a RH involvement in anger, disgust, happiness and
sadness recognition. Our data showed no association
between RHD and emotional processing based in affective
pictures, both subjectively and physiologically. Hence,
P3-48
MUSICAL HALLUCINATIONS: CORRELATION WITH
CHILDHOOD ABUSE: A CASE REPORT AND LITERATURE
REVIEW
Lead Author: Ritika Baweja, M.D.
Co-Author(s): Mark Rapp, MD, Raman Baweja, MD, Amol
Chaugule, MD
SUMMARY: Auditory hallucinations have been classified into
two subtypes: verbal and non-verbal, musical hallucinations
(MH) being considered non-verbal subtype. We here present
a unique case of 83-year-old woman with chronic hearing
impairment who presented with abrupt onset of musical
hallucinations (MH) experiencing recognizable songs from
her childhood. MH worsened when faced with psychosocial
stressors similar to those experienced during her childhood
which reminded her of emotional trauma which she suffered
then. Mental status examination was unremarkable except
for MH and generalized anxiety. Her neurological evaluation
was unremarkable. Even though she enjoyed those songs in
her childhood, but MH gradually incorporating disturbing
content in the voices of her grandson and great-grandson
gradually became very distressing to her. MH have significant impact on functioning which someone would imagine
with other modalities of perceptual abnormalities. Etiology
of MH appears to be multifactorial; this can also be nonpathological in origin especially in children and young
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patients' frequency of binge drinking when assessing the risk
for suicide.
emotion recognition and emotion processing could be
suggested being independent cognitive processes. Despite
these findings, more research is needed, as inconsistent
results can be found in literature.
P3-51
EXPLORING BARRIERS TO TREATMENT IN PATIENTS
WITH PSYCHOTIC DISORDERS: INSIGHTS FROM THE
STAR INTENSIVE OUTPATIENT PROGRAM
Lead Author: Nidal Moukaddam, M.D., Ph.D.
Co-Author(s): Beatrice Rabkin, Phuong Nguyen, PhD
SUMMARY: Background: Treatment of chronic psychotic
disorders in outpatient settings is fraught with challenges;
these include non-compliance with treatment , comorbid
substance use, ambivalence (and frequently lack of insight)
about diagnosis and need for treatment. The Stabilization,
Treatment, And Rehabilitation (STAR) program, an intensive
twice-weekly multidisciplinary treatment endeavor, was
started to serve this very challenging population. Many
obstacles to treatment were noted. Objective: to summarize
the data and experience of the STAR program's first cohort of
patients Results: The majority of patients were male, with an
average age of 34. Predominant diagnosis was schizophrenia.
Referral rates from inpatient and outpatient units were
satisfactory, but show rate for the initial assessment intake
were less than 40% despite phone reminders. The patient
population displayed moderate to severe symptoms as
indicated by the initial scores on the Positive and Negative
Syndrome Scale (PANSS). (average positive score= 21.1,
average negative scale score= 23.9 and average general
psychopathology score= 48). Other factors noted to influence
compliance were: family support transportation and copay
amounts. Conclusions: Results from our intensive outpatient
treatment program for chronic psychotic disorders suggest
the target population suffers from significant symptoms that
cause functional impairment in multiple areas. Compliance
cannot be ensured without family or community support.
Meaningful improvements were noted in patients who
stayed in treatment.
P3-50
IS THE FREQUENCY OF BINGE DRINKING RELATED TO A
HIGHER RISK OF SUICIDAL BEHAVIOR? AN ASSESSMENT
BY UTILIZING THE C-SSRS IN ADULT PSYCHIATRIC
INPATIENTS
Lead Author: Ahmad Hameed, M.D.
Co-Author(s): Alan J Gelenberg, M.D., Roger E Meyer, M.D.,
Michael A Mitchell, M.A., Amanda M White, Eric A
Youngstrom, PhD
SUMMARY: Introduction: Alcohol use is a significant and
well-established risk factor for completed suicide. Binge
drinking has also been linked to suicide attempts in nonclinical samples. In response to concerns about methodological limitations of suicide instruments, the development
and the use of standardized instruments to assess for
suicidal risk has become crucial in clinical settings. Method:
Data were collected and analyzed as part of an original study
comparing suicide assessment instruments in adult psychiatric inpatients (n = 199; 43.2% male, 56.8% female).
Lifetime and past month suicidal behavior were evaluated
using the Columbia Suicide Severity Rating Scale (C-SSRS). A
Risk Assessment Measure (RAM) collected information
about alcohol use and abuse. Alcohol users reported how
many times per month they binge drank. Analysis: A
secondary analysis was performed to determine if a
relationship existed between suicidal behavior and alcohol
use/abuse in an adult psychiatric inpatient sample. Chisquare tests tested for differences in suicidal behavior
between users and non-users and, among users, between
those who binge drank and those who did not. Gender
differences were also examined. Point biserial correlations
calculated the magnitude of possible relationships between
suicidal behavior and binge frequency. Results: Males and
females did not differ in their suicidal behavior. 54% of
patients used alcohol. Suicidal behavior did not differ
between those who used and those who did not. 65.1% of
males and 45.1% of females were users; gender and user
status did not have an interaction effect on suicidal behavior.
50% of drinkers binge drank at least once a month. Males
and females were equally likely to binge. Suicidal behavior
did not differ between those who binged and those who did
not; gender and binge status did not have an interaction
effect. Moderate positive correlations revealed that males
who had a lifetime and past month history of interrupted
suicide attempt tended to binge drink more frequently.
Among females, a small positive correlation emerged
between past month aborted suicide attempt and binge
frequency. Discussion: Alcohol users and bingers were not
more likely to engage in suicidal behavior and no gender
effects emerged. However, suicidal behavior was associated
with more frequent binge drinking among both male and
female adult psychiatric inpatients. Though being a binge
drinker was not related to suicidal behavior as previous
studies have shown, frequency of binge drinking was related
to suicidal behavior. To the best of our knowledge, linking CSSRS outcomes to frequency of binge drinking in an adult
psychiatric inpatient population is novel. The corelational
results suggest that adult psychiatric inpatients who binge
drink frequently may be at a higher risk for suicidal behavior.
It is imperative that physicians place additional emphasis on
P3-52
PERCEPTION OF LIFE EVENTS FROM PATIENTS
DISCHARGED FROM COMMUNITY MENTAL HEALTH
SERVICES: A LONGITUDINAL ANALYSIS
Lead Author: Thomas L McLean, M.S.
Co-Author(s): Raymond J. Kotwicki, MD, MPH, Phillip D.
Harvey, PhD
SUMMARY: Background. A significant, challenging aspect of
measuring the efficacy of mental health programs involves
longitudinal analysis of patient well-being after discharge
from services. In addition to assessing whether patients
maintain clinical and functional improvements experienced
during treatment, it is also important to directly assess
patient perception of life events after discharge. Methods.
One-hundred twenty seven patients having moderate to
severe mental illness reported perceptions of life events,
using a modified 50-item scale (LEQ; Norbeck, 1984). This
scale was given multiple times after they were discharged
from services from a private mental health facility
emphasizing a self-recovery model. Time since discharge
was measured in days since discharge, and all patients had
times since discharge ranging from 3 days post discharge to
730 days since discharge. Factor analytic methods were used
to verify the validity of life event categories. Longitudinal
analyses were done on repeated measures of the LEQ to
assess how perceptions of life events changed over time.
Results. Factor analytic methods reduced the number of life
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
event categories into three primary groups: an institutional
life events factor, personal well-being factor, and an
interpersonal factor. Repeated measures analysis demonstrated that overall, clients reported greater positive perceptions of life events over time, with the exception of the
institutional life events factor. In addition, discharge status
and length of stay both moderated this relationship.
Implications. Patients, particularly those who completed
treatment and had longer lengths of stay, reported increasing
positive perceptions of life events over time since discharge,
with the exception of life events related to institutional
organizations (work, school, and crime/legal). This finding is
consistent with research showing long-term benefits of
mental health care emphasizing a self-recovery model.
Further research should examine both the internal (personal
clinical status, functioning status) and external (continued
care with other mental health entities) factors that may be
related to how patient perceptions of life events change over
time after discharge from a mental health program.
P3-54
A 68-YEAR OLD CAUCASIAN FEMALE WHO PRESENTED
TO THE OUTPATIENT CLINIC WITH GENERALIZED
PRURITUS
Lead Author: Muhammad Puri, M.D., M.P.H.
Co-Author(s): Kalliopi Stamatina MD
SUMMARY: The patient being presented in this case report is
a 68 year old caucasian female, who presented into our
Outpatient clinic with a chief complaint of generalized
pruritus. She reported that this condition had first presented
two year before, when she began feeling nervous and had
sensations of insects crawling on her body. During initial
interviewing she again started experiencing crawling feelings
on her body and scalp, and she intensely started to scratch
her scalp, arms, and lower back. After further questioning
she alleged that she has insects crawling on her scalp and she
could see some small worms coming out from the lessons on
her body. She brought several scrapings from her lessons
with her for examination. The patient also reported that she
has sprayed her trailer several times for fleas, and that she
has used multiple times in the past nizoral shampoo,
doxycycline and elimite creams, and vermox. Examination
revealed a pleasant and cooperative anxious Caucasian
female in no distress. Numerous excoriations on both upper
extremities, lower back, and scalp were noted. A purulent,
scant amount of serous fluid was seen in the lessons, and
some had keratin deposits. Laboratory examinations
revealed normal serum electrolytes and CBC, negative serum
ANCA, negative serum ANA and negative DS-DNA antibody.
Serum TSH was also within normal limits. Biopsy was
conducted from scraping of the lesions, and showed nonspecific inflammation, and negative results for fungus with
KOH preparation. After the results of the biopsy were
reviewed patient was started on treatment with Olanzapine
5mg/day. In a one month follow-up visit, the patient
reported that the parasites no longer troubled her and her
dose was increased to 10 mg/day. Within a period of sixmonths under therapy with Olanzapine the patient presented in complete remission. No adverse effects were reported
by the patient and the treatment was tapered off. The patient
was being followed for the following 6 months and she
remained stable with no relapse to her previous symptoms.
P3-53
20 YEAR OLD MALE WITH HELIUM-INDUCED SUICIDE
ATTEMPT
Lead Author: Muhammad Puri, M.D., M.P.H.
Co-Author(s): Deepti Mughal, MD, Kalliopi-Stamatina
Nissirios, MS
SUMMARY: We report a case of a 20 year old Caucasian male
who was admitted in our psychiatric unit on an involuntary
basis after being brought to the Emergency Department, by
911 Emergency Services, for an attempted suicide with the
use of a Helium tank and mask. Patient's chief complaint is a
chronic Depression since the age of 13 that has never been
managed. From a review of the patient's medical records,
and after interviewing the patient and his parents, a history
of Depression is noted for the past seven (7) years. There are
no reports of past inpatient or outpatient psychiatric treatments, apart from a previous attempt to suicide with the use
of pills at the age of 16 years old for which he only received
some counseling. The patient was admitted to our inpatient
psychiatric unit for management, treatment and education
about his depression. The purpose of this case report is to
analyze the process of assisted suicide by oxygen deprivation
with Helium, and to highlight the increasing occurrence of
suicidal attempts by the use of this method.
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AMERICAN PSYCHIATRIC ASSOCIATION
of communicating and has a significant impact on the way of
life among its users. However, the effect of social media on
medicine, especially psychiatry, has not been well studied.
This is a report of Facebook associated suicidal ideation.
Methods A case of suicidal ideation leading to inpatient
psychiatric hospitalization following the use of Facebook is
discussed. The literature on social media's impact on mental
illness, identified by a PUBMED search, using the key words:
Facebook, social media, suicide, psychiatry, is reviewed.
Results Mr. K.M. is a 53-year-old male with a past psychiatric
history of Major Depressive Disorder, PTSD and alcohol
dependence. Patient logged onto Facebook and found that
his ex-girlfriend had "de-friended him" and subsequently
became suicidal. Patient contacted the suicide hotline and
was admitted to an inpatient psychiatric unit. Discussion
The impact of the Internet on suicide has been well
established (1). In recent years there has been increased use
of social media, especially among teenagers and young
adults. Psychological sequelae have been described with
some social media. In a paper by Wolniczak et al., Facebook
usage was associated with poor quality of sleep in over 50%
of users (2). In another report, a patient announced suicidal
ideation on Facebook (3). However, there are no reported
cases in the literature of Facebook induced suicide attempt
or suicidal ideation precipitating psychiatric hospitalization.
Social media has advantages including facilitating communication and free access to information. It also encourages
sharing personal information, which may lead to negative
consequences such as envy, jealousy, rage and cyber
bullying. Social media as a means of communication can
encourage suicidal behavior via the copycat syndrome (4). If
used appropriately, social media can be a powerful
communication tool and can ultimately be a benefit to
patients. Conclusion This case illustrates that using social
media can precipitate suicidal ideation in people with poor
coping skills. Clinicians and practitioners dealing with the
mentally ill should be aware of this risk associated with use
of social media. References
POSTER SESSION 4
P4-1
MANIA FOLLOWING ECT TREATMENT FOR DEPRESSION:
A CASE REPORT
Lead Author: Ashley J.B. MacLean, B.Sc., M.D.
Co-Author(s): Dr. Adekola Alao; Dr. Marideli Lopez
SUMMARY: Background The use of electroconvulsive
therapy (ECT) is a well-recognized treatment for depression.
However, ECT precipitated mania, following treatment for
depression, and the underlying mechanism has not been
well studied. Methods A case of mania following ECT treatment for depression is discussed. The literature on the side
effects of ECT is reviewed. Results Patient is a 31-year-old
male initially admitted to an inpatient psychiatric unit for
depression and suicidal ideation. Patient carried a diagnosis
of major depressive disorder, substance use disorder and
substance induced psychotic disorder. After the patient
failed to respond to different pharmacological agents he was
treated with 11 session of ECT over a 5-week period. The
patient's depressive symptoms resolved following ECT
treatment; however he developed an elated and expansive
mood, racing thoughts, pressured speech and grandiose
delusions. He was easily distractible and tangential. Patient
was subsequently diagnosed with mania secondary to ECT
treatment. His antidepressant was stopped and he was
eventually stabilized and discharged on risperidone 2mg
BID, Cogentin 1mg daily and divalproex sodium ER 1000mg
QHS. Discussion There has been only one prior report in the
literature of ECT precipitated mania following treatment in a
patient diagnosed with depression with psychotic features
(1). Several theories exist to explain the mechanism underlying how ECT treats depression including the neurotransmitter, anticonvulsant, neurotrophic, and monoamine
neurotransmitter theories (2). It is well known that antidepressants can precipitate mania in a patient with bipolar
disorder. The patient presented here did not have a previous
history of bipolar disorder but developed mania following
ECT. Interestingly, ECT can also be used to treat prolonged
mania. Studies have demonstrated that fewer sessions of
ECT are required to treat bipolar depression versus unipolar
depression. ECT precipitated mania in a patient with a
history of bipolar disorder may be secondary to neurotransmitter changes following ECT (3). Conclusion This case
illustrates a rare adverse effect of ECT (mania). Is the
underlying neurological mechanism by which antidepressants can induce mania related to the mechanism by which
ECT induces mania? Since ECT is used frequently and manic
symptoms have not been reported following ECT, there is a
need for further empirical research on this subject.
References
1. Alao AO, Soderberg M, Pohl EL & Alao AL: Cybersuicide: Review of the
Role of the Internet on Suicide. Cyberpsy., Behavior, and Soc.
Networking 2006; 9(4): 489-493.
2. Wolniczak I, Cáceres-DelAguila JA, Palma-Ardiles G, Arroyo KJ,
Solìs-Visscher R, Paredes-Yauri S et al: Association between Facebook
dependence and poor sleep quality: a study in a sample of undergraduate
students in Peru. PLoS One 2013; 8:e59087.
3. Ruder TD, Hatch GM, Ampanozi G, Thali MJ & Fischer N: Suicide
announcement on Facebook. Crisis 2011; 32:280-2.
4. Tor PC, Ng BY& Ang YG: The media and suicide. Ann Acad Med
Singapore 2008; 37(9):797-9.
P4-3
HARD TO SWALLOW: A CASE REPORT OF A SERIAL
FOREIGN BODY INGESTER
Lead Author: Kevin C Hails, M.D.
Co-Author(s): Emily Bray, DO; Subani Maheshwari, MD;
Russell Foo, MD
SUMMARY: The ingestion of foreign bodies can be seen in a
variety of psychiatric patients. Psychosis, malingering, personality disorders and other processes may all contribute to
the ingestion of foreign bodies. Once ingested, the patient
may require invasive procedures. Although rare, it can be an
extensive clinical challenge requiring close psychiatric
observation. These patients can impose clinical and emotional burdens on health care providers and lead to
frustration and negative reactions within the clinical team.
We first present the case of DH, a 24 year old female with an
extensive psychiatric history whose multiple ingestions were
1. Saatcioglu O & Guduk M: Electroconvulsive therapy-induced mania: a
case report. J Med Case Reports 2009; 3: 94: 10.1186/1752-1947-3-94
2. Kellner CH, Greenberg RM, Murrough JW, Bryson EO, Briggs MC,
Pasculli RM. ECT in treatment-resistant depression. Am J Psychiatry
2012; 169(12):1238-44.10.1176/appi.ajp.2012.12050648
3. Agarkar S, Hurt S, Lisanby S, & Young RC: ECT use in unipolar and
bipolar depression. J ECT 2012; 28(3):e39-40. doi:
10.1097/YCT.0b013e318255a552
P4-2
TIME TO FACE IT: SUICIDAL IDEATION AND FACEBOOK
Lead Author: Ashley J.B. MacLean, B.Sc., M.D.
Co-Author(s): Dr. Adekola Alao
SUMMARY: Background Social media, such as Facebook,
Twitter, YouTube, etc., is increasingly being used as a means
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
admitted to the psychiatric unit after a suicide attempt. She
also had paranoia and auditory hallucination. She became
hypotensive the next day and was transferred to the medical
unit. After stabilization, the patient was readmitted to the
mental health unit, where her hypotension persisted for a
few days. The patient then developed hyponatremia which
was investigated by the internal medicine team. At this time,
her spouse provided vital information that the patient had
been receiving intramuscular corticosteroid injections every
three months for the past four years. They were administered
by her primary care physician to treat fibromyalgia. He also
reflected that every time she received injection, her mood
and psychotic symptoms would worsen. Further laboratory
investigations supported the diagnosis of adrenal insufficiency secondary to exogenous corticosteroids use. Patient's
psychotic symptoms improved when oral corticosteroids
were added to her regimen, even though she did not respond
to antipsychotic medications previously. Ms. B, a 58-year-old
female with a history of schizoaffective disorder, was
admitted for paranoia and delusions of persecution worsening over the last eight months. Before the admission, patient
was just treated for acute renal failure in the medical unit.
She had comorbid multiple sclerosis and Parkinson-plus
syndrome. Her paranoia was partially responsive to
antipsychotic medications, but she continued to display
paranoia toward staff on the unit as well as other patients.
Neurologist reported that she had been receiving intravascular methylprednisolone injections on a monthly basis
for multiple sclerosis, the duration of which corresponded to
the time frame of worsening of symptoms. Both patients
were discharged with a diagnosis of Steroid-Induced Psychotic Disorder. Discussion: We report these cases together to
stress upon the importance of a thorough medical history to
establish an early diagnosis of psychiatric illness due to
medical conditions. This, in turn, will lead to timely etiology
identification and better patient outcome.
followed by lengthy hospitalizations and multiple surgical
procedures. She was diagnosed with both Axis I and
personality disorders. She was essentially refractory to
psychotherapy and psychopharmacology. Then historical
cases will be reviewed followed by the differential diagnoses
for patients with serial foreign body ingestion. Treatment
options will also be considered including psychopharmacology and psychosurgery. Behavorial treatment plans will
be also examined. The education of staff is deemed very
important and will be reviewed. In the above case psychiatry
was actually blamed for her behavior and not being able to
"fix her." Use of multidisciplinary tools will be reviewed.
P4-4
EPIDEMIC OF KORO IN NORTH EAST INDIA: AN
OBSERVATIONAL CROSS-SECTIONAL STUDY AND
LITERATURE REVIEW
Lead Author: Vishesh Agarwal, M.D.
Co-Author(s): Rajesh Kumar, M.D., Hemendra R. Phookun,
M.D.
SUMMARY: Background: Koro is a culture bound syndrome,
endemic to South-East Asia and known to present as an
epidemic. It is an unshakable belief of retraction of one's
genitalia into the abdomen accompanied with fear of death.
The first epidemic in India was seen in 1968 in the state of
West Bengal. Objective: An observational cross-sectional
study conducted in 2010 over the course of a week,
correlating socio-cultural and demographic variables of 70
patients who presented with this syndrome in the north
eastern state of Assam, India. Method: Data collected in an
organized format from 70 cases seen in emergency department and outpatient clinic who met the diagnostic criteria
for Koro based on DSM IV. Published literature on Koro was
reviewed. Results: Of the 70 patients included in study, 97.1%
(n=68) were males, 60% married (n=42), and 62.9% (n=44)
from lower socio-economic status. 68.6% (n=48) presented
to the emergency department and 85.7% (n=60) reported
attack at home with more people reporting it in the evening
or night 62.9% (n=44). The most common presenting
symptoms were tingling sensation in thighs, shortening of
the penis and severe anxiety with fear of death. Patients were
referred for psychotherapy and most showed good response
to supportive and insight oriented psychotherapy. Conclusions: Koro commonly presents in an epidemic form as an
acute anxiety state. Although reasons remain unclear, some
accounts relate this to the wide media coverage and news
reports. It appears to have a good prognosis and patients
respond well to psychotherapy. Key words: Koro, culture
bound syndromes, acute anxiety, and psychotherapy.
P4-6
SEEING DOUBLE: SERTRALINE AND DIPLOPIA
Lead Author: Adekola Alao
Co-Author(s): Claire Lewkowicz
SUMMARY: Introduction Sertraline is an antidepressant in
the class of selective serotonin reuptake inhibitors (SSRIs),
and along with the other SSRIs, it has become a mainstay in
the pharmacologic management of major depression and
related mood disorders. In this report, we describe a 34-yearold man who developed diplopia after treatment with sertraline. To the best of our knowledge, this is the first reported
case of sertraline-induced diplopia. Case Report A 34-yearold male veteran with a history of PTSD and major depresssion stabilized on citalopram 20 mg daily. Due to a lack of
efficacy after a year, the citalopram dose was gradually
titrated down. After one week, the patient was started on
sertraline, 50 mg daily. Two days after his first dose of
sertraline, he started having double vision, as well as light
sensitivity. He stopped taking the sertraline, and these
symptoms disappeared. The patient re-challenged himself
with sertraline at a lower dose of 25 mg daily after 3 days and
he had a recurrence of diplopia as well as blurred vision.
Discussion Two cases of diplopia after citalopram ingestion
have been reported in the literature. The acute onset of
diplopia in this patient following sertraline treatment, in
addition to the rapid resolution of the diplopia and reoccurrence after re-challenge indicates an association between
this adverse effect and the drug. Although considered very
P4-5
DEVIL IS IN THE DETAILS: THE IMPORTANCE OF
OBTAINING THOROUGH MEDICAL HISTORY
Lead Author: Clarice Chan, M.D.
Co-Author(s): Swapnil Khurana, M.D.; Pankaj Lamba, M.D.;
Babu Jarodiya, M.D. Nabila Farooq, M.D. William Cardasis,
M.D.
SUMMARY: Introduction: Although it is well-established that
medical disorders can first present with psychiatric symptoms, such presentations are rare in practice. As a result,
medical diagnoses are sometimes overlooked at initial
presentation. Herein, we report two cases of psychosis in
elderly patients admitted to our psychiatric unit that
appeared to be related to organic causes. Cases: Ms. A, a 68year-old female with no past psychiatric history, was
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AMERICAN PSYCHIATRIC ASSOCIATION
Report 20 year old male with a history of anorexia nervosa
was admitted at the ED unit in a freestanding psychiatric
hospital for severe food restriction, weight loss of 20 lbs in 3
months and alcohol abuse. BMI on admission was 12 with a
body weight of 66.4 lbs which was <70% ideal. Strict bed rest
and anorexia protocol was initiated. He continued to restrict
food leading to severe dehydration, critical electrolyte
imbalance and EKG changes that required immediate
transfer to inpatient Medicine. Given the life threatening
condition a decision for feeding tube placement was made.
Once medically stabilized, he was admitted to a Geriatric
Psychiatry inpatient unit in a general medical hospital for
close monitoring of input/output and tube feeding adjustments. He continued to resist oral intake, started purging
and exercising. He also started dumping food via feeding
tube leading to further hypokalemia and required IV fluids
and eletrolyte repletion. Closed observation, eye sight and a
behavior plan was implemented which included bed side
commode and strict rules for meals. Olanzapine was started
for mood stability. He gradually started to gain weight. He
was discharged home with visiting nurse and a referral for
dialectical behavioral therapy. BMI at discharge was 15.1
with a body weight of 80 lbs. Discussion Identifying and
treating ED in men is challenging. Doctors are less likely to
diagnose ED in men. Men comprise approximately 10% of
persons with eating disorders. They often try to achieve a
better body image through bodybuilding, weightlifting, and
muscle toning. A study noted that some of the popular male
action figures have grown extremely muscular over time. ED
are often associated with depression, anxiety and substance
use. Given the high mortality and morbidity a holistic
approach of pharmacotherapy, psychotherapy and treating
associated psychiatric and medical comorbidities appears
warranted. It is also important to counsel parents, teachers,
athletes and fashion industry coaches for early recognition of
warning signs and risks of eating disorders.
References
safe, rare and serious ocular side effects of SSRIs, including
angle-closure glaucoma have been reported. Receptors for
serotonin have been discovered in the eye, strongly
suggesting a functional role for this neurotransmitter in
ocular tissue. Conclusion Although further research is needed to establish the cause of sertraline-induced diplopia, this
case illustrates the importance of increased patient and
physician vigilance for this possible adverse effect.
P4-7
IMPLEMENTING DBT INFORMED NURSING CARE IN AN
ACUTE PSYCHIATRIC SETTING
Lead Author: Stamatis A Zeris, M.D.
Co-Author(s): Adam Carmel PhD; Javier Rizo BA; Carrol
Alvarez ARNP
SUMMARY: Introduction: We report a case study of
implementing Dialectical Behavioral Therapy (DBT)
informed acute psychiatric nursing care in a large public
safety net hospital through an interactive staff training
model. Purpose of Report: Describe the implementation of
an evidence based treatment for borderline personality
disorder on inpatient and emergency psychiatric units of a
large public hospital. Discuss and review the challenges
encountered during implementation, including staff burn
out, negative attitudes towards individuals with borderline
personality disorder, and what role DBT training played in
addressing these obstacles. Describe future directions for
implementation of DBT informed nursing care. Implementation: Phase one of implementation engaged staff with a
needs assessment. Phase two involved the implementation
of the program with outside DBT consultant guidance. Phase
Three, piloting the program through a "Train the Trainers"
model, a larger subgroup of nurses and staff provided more
information about obstacles in implementation and helped
trouble shoot those challenges. Phase four, future directions
were discussed with the staff group in order to maintain and
grow the program including bi-monthly staff consultation
groups and a behavioral chain analysis tool used in the
emergency department. Conclusion: Evidence based
psycho-social treatment, such as DBT though heavily
researched, still faces many barriers to implementation in
certain treatment setting. This is especially true in acute
setting heavily influenced by a bio-medical culture.
However, using evidence based implementation strategies;
hospital administration can increase the likelihood of
adoption of these practices.
1.Sullivan PF. Mortality in Anorexia Nervosa. Am J Psychiatry. 1995
Jul;152(7):1073-4
2.Pope HG, Olivardia, R. Gruber A, Borowiecki J. Evolving ideals of male
body image as seen through action toys. International Journal of Eating
Disorders, 26, 65-72, 1999.
P4-9
GRAVES DISEASE AND ITS PSYCHIATRIC
MANIFESTATIONS: A CASE REPORT
Lead Author: jose a alvarez, M.D.
Co-Author(s): Luisa Gonzalez M.D.; Panagiota Korenis M.D.
SUMMARY: Imbalances in the thyroid hormone have been
shown to cause numerous psychiatric sequelae incuding
affective, anxiety and psychotic symptoms. Hypothyroidism
as well as hyperthyroidism can result in the production of
psychiatric symptoms and can often be misdiagnosed as a
primary psychiatric disorder. While there have been numerous studies illustrating the affective symptoms associated
with hyperthyroidism there have been few demonstrating
the devastating effects of both uncontrolled hyperthyroidism
and concomitant neuropsychiatric symptoms. We present a
patient with uncontrolled Grave's Disease who had decompensated with agitation, affective instability, delusions and
paranoia. This case aims to illustrate the potential for exploring both psychiatric as well as endocrinologic bases for
psychiatric presentations and hopes to add to the growing
list of evidence for psychiatric sequelae in thyroid dysfunction.
P4-8
EATING DISORDERS IN YOUNG MEN: CASE REPORT AND
LITERATURE REVIEW
Lead Author: Subani Maheshwari, M.D.
Co-Author(s): Vishesh Agarwal, M.D., Boris Itskov, M.D., Marc
H. Zisselman, M.D.
SUMMARY: Background Eating disorders (ED) are serious
and potentially life threatening conditions. Anorexia Nervosa
has the highest mortality rate in all psychiatric disorders.
Potential predictors of mortality include medical complications such as electrolyte changes, severity of weight loss,
severity of co-occurring psychopathology and severity of the
ED symptoms. Men suffering from ED have an immense
stigma to overcome and feel hesitant seeking help.
According to National Eating Disorder Association, 10
million males in the United States will suffer from a
significant eating disorder at some time in their life. Case
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
previously treated for syphilis in 1992 and 2010. He was
compliant with HAART, had an undetectable viral load
9/2012-3/2013, no history of opportunistic infections, 6/2013
CD4 646/viral load 146, no past psychiatric history until 9
months prior when he was managed for mania at another
hospital. Diagnosis of neurosyphilis was confirmed with LP,
he received IV PCN and Risperidone, which was discontinued prior to discharge. He had a follow up LP 5 months
later and received IM PCN for management of latent syphilis.
Patient had full remission of symptoms and no psychiatric
follow-up after receiving IM PCN. Current workup showed:
Brain CT --Diffuse cerebral atrophy, hypo-attenuation in the
periventricular white matter bilaterally, punctate calcifications within the subcortical white matter bilaterally as well as
vascular calcifications .CD4 -772 and Urine ToxicologyCannabinoids and VDRL(-), RPR 1:8, Syphilis IgG Ab
Reactive and CSF-WBC 20 cells/ul, Elevated Protein 108mg,
Normal Glucose. Patient was started on Lithium Carbonate
300mg BID, Zolpidem 10mg qhs, Quetiapine 100mg BID. A
presumptive diagnosis of neurosyphilis was made and a 2week course of IV PCN was started. Within a few days manic
symptoms resolved, Lithium was discontinued and Quetiapine was increased to 300mg daily. Discussion: Neurosyphilis usually occurs in people with chronic and untreated
syphilis. In a 2008 study of neurosyphilis cases 1965-2005 by
Mitsonis, et al, there were no cases of general paresis and
tabes dorsalis after 1985. 1985-2005, 53.5% of cases
presented with only cognitive impairment and psychiatric
manifestations. In a retrospective study of neurosyphilis
cases 1985-1992, 64% of 117 cases of neurosyphilis were
HIV+. Of the 33% who were asymptomatic, 71% were HIV+.
.In one study, 59 HIV+ subjects with neurosyphilis were
followed up for 6.9 months. HIV+ subjects were found to be
2.5x less likely to normalize CSF VDRL reactivity. If their CD4
counts were <200, the odds are even decreased to 3.7x.This
patient presented with exclusive behavioral manifestations
and had a history of similar presentation, was diagnosed
with neurosyphilis, and experienced symptom resolution
after treatment with PCN and antipsychotic medication.
Conclusion: Patients with new-onset behavioral changes or
a rapid decline in mental status should be screened for HIV
and syphilis. In the absence of a guideline, patients with
neuropsychiatric manifestations of syphilis and HIV may be
treated with mood stabilizers plus antipsychotics and
standard PCN treatment.
P4-10
SPECIFICS OF COGNITIVE PROFILE OF LATE ONSET
DEMENTIA WITH DELUSIONAL SYMPTOMS
Lead Author: Irina Sokolova, M.D.
Co-Author(s): Alena P Sidenkova
SUMMARY: Summary Psychotic symptoms are often
observed in late onset dementia. They complicate its course.
We designed this study to examine the impact of cognitive
deficits on development of psychotic symptoms in dementia.
Material and methods of research. We ran comparative unrepeated prospective observational study of patients with
dementia. The study included 161 patients, both males and
females. The main group had 105 patients from 61 to 81
years of age, diagnosed with dementia with delusional
symptoms. The control group included 56 patients aged
from 56 to 78 years of age, diagnosed with dementia without
delusional symptoms. Methods included clinical, psychopathological, neuropsychological and psychometric research. Results and discussion At the beginning of the study,
100% of patients were diagnosed with mild dementia (MMSE
20-23 points). The main study group revealed fable (??)
heterogeneity of delusions. Specifically, persecutory delusions were found in 58 (55.2%) of older people in the main
group. Delusions of jealousy were found in 33 people (31.4 %
of cases); Fourteen percent (13.3%) of patients had delusions
about people stealing from them (p < 0,0001). The study
showed that 77 patients in the main group (73,3%) did not
have perceptual deficits. Verbal disturbance was detected in
22 patients (21%). Regarding mood instability, we traced
transition of affect from cooperatively elated to aggressive in
29 patients of the main group (27,6%). Prolonged dysthymia
worsening during minor environmental changes, was
observed in 12 patients (11,4%) (p<0.0001). Persistent sleep
problems and nocturnal disturbances were found in the
majority patients of the main group: 36 patients (34,3%) had
difficulty falling asleep, 49 people (46,7%) had interrupted
sleep on multiple occasions, wandering while awake
(p=0.001). Eating disorders were significantly more prevalent
in the main group of the study (p=0,027), with reduced
appetite in 36 cases (34,3%). According to correlation
analysis, delusional thoughts correlated significantly with
perceptual disorders (r = -0,231 *, p = 0,018), anxiety (r = 0,323 **, p = 0.001), irritability / instability of mood (r = -0,326
**, p = 0.001), apraxia (r = -0,476 **, p <0.0001), agnosia (r = 0,526 **, p <0.0001). The direct correlation was observed
between delusional ideations and agitation / aggression (r =
0,469 **, p <0.0001). Therefore, we established statistically
significant results, comparing cognitive deficits of two types
of dementia, including dementia with and without
delusions. We observed difference in structural psychopathological profiles of both types of dementia.
P4-12
MENTAL HEALTH URGENT CARE CLINIC UTILIZATION BY
ACTIVE DUTY SERVICE MEMBERS AND MILITARY
VETERANS IN A HYBRID FEDERAL HEALTH CARE
FACILITY
Lead Author: Vamsi K Garlapati, M.D.
Co-Author(s): 2. Charles Ludmer, M. D.; Zafeer Berki, M. D.
SUMMARY: On October 01, 2010 the United States
Department of Veterans Affairs (VA) and Department of
Defense (DoD) integrated their facilities, services and
resources to become a first-of-its-kind Federal Health Care
Center in North Chicago, Illinois. The authors present
retrospective comparative data analysis of utilization of the
urgent care clinic in the mental health department of the
hybrid federal health care facility by the active duty military
service members and military veterans, diagnoses and the
reasons for visit and how the data pertains to future of hybrid
federal health care facilities.
P4-11
RECURRENT MANIA IN A PATIENT WITH
NEUROSYPHILIS AND HIV
Lead Author: Amilcar A. Tirado, MD, MBA
Co-Author(s): Elisa N. Simon, MD, Steven Vargas, MD, Raj
Addepalli, MD
SUMMARY: Introduction: This is a case of a patient with
neurosyphilis and HIV, presenting with recurrent mania.
Case Presentation: A 45 year-old homosexual man, HIV+ for
22 years, on HAART presented to the ER in 7/2013 agitated,
with loud pressured speech, and expressing grandiose
delusions. Patient experienced symptoms for 1 week, his
review of systems and physical exam was normal .He was
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AMERICAN PSYCHIATRIC ASSOCIATION
P4-14
INFLUENCE OF BIOLOGICAL AND MICROSOCIAL
FACTORS ON SYMPTOMATOLOGY OF DEMENTIA AS A
SYNDROME
Lead Author: Alena Sidenkova, Ph.D.
Co-Author(s): Irina Sokolova
SUMMARY: Relevance. Cognitive disorders are frequently
found in the population. Mechanisms of development of
dementia has not been studied well enough, so the relevance
of studies is significant. The purpose of this study. The
current study is related to psychosocial and neuropsychological mechanisms of basic manifestation of dementia.
Materials and methods. The current study is a prospective
observational study involving patients with Alzheimer's
dementia, as well as patients with vascular dementia. This
study involves the main group of 214 patients with dementia
living with families, as well as a control group of 101 patients
living in nursing homes. Methods of study include clinical,
clinical—psychopathological, neuropsychological, psychometric, sociometric and statistical. Results. Patients with
mild to moderate dementia were found to have a greater
degree and frequency (p <0,05) of symptoms in comparison
with patients who lived in nursing homes. Those symptoms
included affective and behavioral symptoms (anxiety, irritability/unstable mood, agitation/aggression, aberrant motor
activity, behavior disorders, nocturnal disturbances), and
psychotic symptoms (bizarre delusions, perceptual disorders). Apathy was found significantly more frequent (p
<0,05) in patients in nursing homes. Disorders of superior
brain functioning such as speech, gnosis, praxis, are essential
in psychopathology of dementia. Speech disorders and
agnosia contribute to development of bizarre delusions (r =
0,891), disorders of perception (r = 0,798), eating disorders (r
= 0,688), affective symptoms (r = 0,566). Abnormal behavior
(r=0,850), agitation/aggression (r=0,623), circadian disturbances (r = 0,723) occurred in severe dementia (p <0,05).
Decreased activity level, poor communication, and poor
ability to navigate were more common for patients from the
main study group (p <0,05). Patients with low functional
activity level do not respond to environmental changes if
cases included severe dementia (r = 0,835), total aphasia (r =
0,631), and apraxia (r = 0,610). Decreased functional activity
of patients (r = 0,758), abnormal behavior (r = 0,675),
agitation / aggression (r = 0,713), nocturnal disturbances (r =
0,597), anxiety (r = 0,685) were contributing to increased
emotional pressure on caregivers. Therefore, it worsened
social, occupational, and marital status of caregivers for
patients with moderate or severe dementia (p <0,05). More
severe patients' dementia indirectly affects functional
activity (r = 0,758) of caregivers. The caregivers often suffer
from neurotic, affective and other psychiatric disorders (74.5
%). Change in family bounding or place to stay, with higher
level of " expressive " emotions from caregivers, significantly
affected psychosis (r = 0,618), anxiety (r = 0,701), the deviant
behavior (r = 0,837) in patients with dementia . Conclusion .
Symptomatology of dementia depends on multiple
biological and microsocial factors.
P4-13
THE PERINATAL EMOTIONAL WELLNESS PRACTICE; A
MODEL FOR THE INTEGRATION OF PSYCHIATRY INTO
OBSTETRICAL CARE
Lead Author: Erin Morrow, M.D.
Co-Author(s): Anna Glezer M.D.
SUMMARY: The purpose of this poster is to describe and
demonstrate the integration of a psychiatry clinic into a
primary care setting. Specifically, we will discuss the
Perinatal Emotional Wellness Practice at UCSF Medical
Center. This clinic is embedded within the Obstetrics Clinic,
providing mental health services to women who are in the
preconception planning stage, pregnant, or postpartum. In
this presentation, we will describe the most commonly
diagnosed mood disorders in the peripartum period, and
how they affect women and their offspring during pregnancy, childbirth, and beyond. We will discuss studies that
have demonstrated negative outcomes in both mother and
child when mood disorders are left untreated. These include
an association between maternal depression during pregnancy and increased odds for premature delivery and
decreased breastfeeding initiation, as well as effects on
society through overuse of healthcare resources and loss of
productivity (1-3). We will also focus on the integration
process of the Perinatal Emotional Wellness Clinic into
primary care obstetrics at UCSF. In recent years, psychiatry
has successfully participated in collaborative care within
primary care settings (4,5). Almost 60 percent of people with
depression are treated outside of mental health clinics, but
studies show that 25-50% are not accurately diagnosed, and
of those who receive accurate diagnoses, 50% do not receive
adequate treatment (6). Women's healthcare is no exception,
as one third of women regard their ob-gyn as their primary
care provider, but only 20-33% of women with depression
are accurately diagnosed in ob-gyn clinics (7). Even when
depression or anxiety is recognized, it has been shown that
two thirds of primary care physicians in 2004/2005 were
unable to refer patients to specialist mental health services
(6). Women's health providers have reported they are
concerned that their practices cannot easily make a prompt
mental health referral, which is a barrier to mental health
treatment (8). We will describe how obstetrical providers
identify women in need of a mental health assessment, and
how the referral process works, as well as speak to the
experience the obstetrical providers have had since the
inception of this clinic and how this has changed
management and care for these patients. Finally, we will
describe how women are evaluated and followed once they
become part of the clinic. As part of this discussion we will
review the Edinburgh Postnatal Depression Scale scores of
women seen at the Perinatal Emotional Wellness Clinic over
a one-year period. This review will look at the EPDS scores
that were recorded at each visit, and look for any change in
score over the course of treatment. At the conclusion of our
poster presentation, we will hope to have shown a successful
example of how perinatal care can be enhanced and
improved by facilitating access to mental health services.
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
Discussion and Conclusion It is not uncommon for patients
with severe pain to express suicidal ideation in order to
convey the intensity of their pain or to manipulate
physicians into providing more treatment. Despite the fact
that many SCD patients are well known by ED physicians for
pain crises requiring analgesics, there are no documented
cases of malingering among SCD patients. Instead, clinicians
may assume that the patient's plea for narcotics is a sign of
drug abuse or addiction, and tension between the patient
and physician often results, especially if an adequate
analgesic dosage is not provided. This is not beneficial to
either party. Our recommendation is that a patient with
documented SCD in vaso-occlusive crisis should be
aggressively treated unless there are clear indications that
the patient is malingering.
References
P4-15
MENINGIOMA AND PSYCHIATRIC SYMPTOMS: A CASE
REPORT AND REVIEW
Lead Author: Subramoniam Madhusoodanan MD
Co-Author(s): Shama Patel, MD; Jonathan Reinharth, MA;
mAdam Hines, BS; Mark Serper, Ph.D.
SUMMARY: Introduction/hypothesis: Atypical presentation
of psychiatric symptoms can lead to a conundrum of
misdiagnoses. Organic causes including brain tumors should
be considered under these circumstances. Methods: We
report the case of an 84 year old woman with irritability,
aggressive, and delusional behavior. Her previous diagnoses
included altered mental status, encephalopathy, dementia,
psychosis- nonspecified, and delirium with delusions. We
suspected the possibility of a brain tumor causing psychiatric symptoms. Results: The Computed Tomography of the
head revealed two calcified meningiomas which did not
require surgery. Neuropsychological testing results suggested the possibility of a frontal lesion causing her psychotic
symptoms. Psychiatric symptoms improved with risperidone. A brief review of the literature is included. Conclusion/Discussion: Brain imaging should be considered in
cases where the psychiatric presentation is atypical. Past
medical records and neuropsychological testing could assist
in the diagnosis.
1. Todd, K.H., Green C., Boham Jr. V.L., Haywood Jr. C., Ivy E. (2006).
Sickle cell disease related pain: crisis and conflict. Journal of Pain, 7(7),
453-8.
P4-17
"THERE TO HELP THEM, NOT TO HURT THEM": PATIENT,
FAMILY MEMBER AND PROVIDER PERSPECTIVES ON
THEIR INVOLVEMENT IN COMMUNITY TREATMENT
ORDERS
Lead Author: Kate Francombe Pridham, M.S.W.
Co-Author(s): Dr. Samuel Law; Gordon Singer; Nicole
Etherington; Dr. Andrea Berntson; Dr. Lorne Tugg
SUMMARY: As Community Treatment Orders (CTOs) and
other forms of compulsory psychiatric community treatment
legislation are increasingly used across North America, it is
important to understand their influence on personal
relationships, community connections, and patient recovery.
This poster will highlight results of a qualitative research
study on the experience of being involved in a CTO. A total of
28 qualitative interviews were conducted with patients,
family members and providers from community mental
health teams serving a marginalized inner-city population in
Toronto, Canada. Four key findings emerged from thematic
analysis: institutional coercion and leverage beyond CTOs in
patient lives; CTOs as the "best available option" in the
current system; influence of perceived and actual CTO
decision-makers on relationships and treatment decisions;
and CTOs' effect on patient insight into illness and
personhood. Based on these findings, the poster will present
recommendations for developing patient-centred and
recovery-focused practice in settings where CTOs are in use.
P4-16
MALINGERING VERSUS "CRY FOR HELP" IN PATIENTS
WITH SICKLE CELL DISEASE
Lead Author: Rachelle M St.Onge
Co-Author(s): Sarah Ventre; Adekola Alao, MD
SUMMARY: Introduction Sickle cell disease (SCD) is a
genetic disorder affecting the molecular structure of
hemoglobin. In genetically homozygous individuals, hemoglobin S makes up more than half of their hemoglobin and
forms polymers when the oxygen supply is reduced. Affected
erythrocytes are rigid, crescent (or sickle) shaped, and
fragile. They are also more adhesive and are prone to block
small blood vessels, thus compromising blood supply to
tissues and bones, leading to painful vaso-occlusive crises.
The use of opioid therapy is common in treating SCD
patients during such crises. However, due to recurrent
episodes, patients develop drug tolerance, requiring
increased dosage and a decreased time interval between
doses (1). This has led to widespread speculation that
patients with SCD may become opioid dependent, though
there has been no scientific evidence to support this
assertion. Case Report The patient is a 27 year-old African
American male with a history of sickle cell disease and
previous hospitalizations for vaso-occlusive crises and
anemia. He arrived to the Emergency Department (ED) with
intense pain in his right leg, not relieved by ibuprofen. He
was treated with meperidine 50mg and rehydrated with
normal saline. After two hours, the ED physician decided to
discharge him. At this point, the patient expressed suicidal
ideation and a psychiatric consult was requested. Upon
psychiatric evaluation, the patient denied any previous
psychiatric history as well as symptoms of depression,
anxiety, psychosis, mania, or hypomania. He denied having
plans to kill himself and admitted that he was exhibiting a
cry for help since his pain was not adequately addressed.
Hospitalization to the medical unit was recommended, as
well as use of patient-controlled analgesia for pain
management. The following day the intensity of the patient's
pain had reduced significantly and he was no longer suicidal.
P4-18
BARRIERS AND FACILITATORS TO HEALTHY LIFESTYLE
AND ENGAGEMENT WITH HEALTH PROGRAMS: MENTAL
HEALTH SERVICE-USERS PERSPECTIVES
Lead Author: Candida R Graham, M.B.B.S.
Co-Author(s): Stephanie Powell-Hellyer, Michelle Fancy,
Christina Boucher
SUMMARY: Mental health service-users have a 20-25%
shorter life expectancy than the general population due to
high rates of cardio-metabolic disorders. Targeted behaveioral programs show moderate improvements but attrition
from such programs is high. Relatively few studies have
explored barriers and facilitators that mental health serviceusers experience in trying to live healthily and participate in
health behavior programs. Such information may help us
improve the efficacy of health behavior programs. The
project "Bridging the C's: Community, Connectedness, and
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AMERICAN PSYCHIATRIC ASSOCIATION
antipsychotics as seen in this case. There may be an
association between prolongation of QTc interval and/or use
of risperidone leading to unmasking underlying cardiac
defect.
Collaboration" established a collaborative partnership
between researchers, mental health service-users and the
wider community in Prince George, Northern British
Columbia, Canada. It is helping to empower mental health
service-users to lead health improvement initiatives aimed at
improving the cardio-metabolic health of individuals with
enduring mental illness. This poster presents data from the
study, highlighting barriers and facilitators to healthy living
experienced by this community. The data adds a rural
perspective and develops concepts of understanding
P4-20
DRUG-INDUCED PSYCHOSIS
Lead Author: Swarnalatha R Yerrapu M.D., M.B.B.S., M.D.
Co-Author(s): Mehnaz Waseem.M.D;Mary J. Bapana M.D;
Stavan R. Patel
SUMMARY: Many medications that we prescribe and use in
daily medical practice have numerous neuropsychiatric side
effects. A systematic and comprehensive review of the
English language literature was performed using Pub med,
PMC Google and Up-to-date to obtain access to publications
pertaining to Psychotic symptoms caused due to the
different classes of drugs. Articles were retrieved, reviewed
and analyzed to find the established connection between
Psychotic symptoms and the ingestion of certain classes of
drugs. Those classes of drugs include 1) Antiretroviral, 2)
Antimalarial, 3) Antibiotics, 4) Antiepileptics, 5) Immunomodulators, 6) NSAIDS, 7) CVS drugs, 8) Antiparkinson, 9)
Antineoplastic. Prompt identification and treatment of drug
induced psychosis results in considerable decrease in
morbidity and mortality.
P4-19
A RARE CASE OF RISPERIDONE CAUSING WPW
SYNDROME: A POSSIBILITY TO BE CONSIDERED AND
CAREFULLY MONITORED IN PATIENTS ON
ANTIPSYCHOTICS
Lead Author: Ritesh Amin, M.D.
Co-Author(s): Daniel M Weiner, BA; Atika Zubera, MD;
Najeeb U. Hussain, MD
SUMMARY: Background: Prolongation of Qtc is a common
adverse effect of the antipsychotics. While it appears to be
rare, a significant body of literature does make mention of
risperidone's ability to prolong QTc. A variety of mechanisms
have been described for this prolongation; Drolet et al.1
propose that risperidone selectively blocks the rapid
component (Ikr) of the heart's delayed rectifier potassium
component. Suzuki et al.2 argue that a metabolite of
risperidone, paliperidone, is responsible for QTc prolongation, and Vieweg et al.3 in their systematic review of case
reports argue that risperidone dosing is not as critical as
other risk factors for QTc interval prolongation and torsade
de pointes. Finally, while Ozeki et al.4 concluded that
second-generation anti-psychotics (SGAs) are less likely than
first-generation anti-psychotics (FGAs) to prolong QTc, they
noted that SGAs (olanzapine, quetiapine, risperidone, and
zotepine) are less likely to prolong QTc interval than FGAs
and SGAs can prolong it as well. Case Presentation: We
report a case of a 45-year-old single male with history of
schizophrenia and no past medical history who presented to
an urban university hospital with active psychosis and non
compliance with medications. Patient was admitted to inpatient psychiatric unit and risperidone 1 mg orally twice
daily was started. Patient developed substernal chest pain
the very next day and cardiac work up was warranted.
Patient was found to have elevated QTc interval as high as
641ms and Wolf-Parkinson White (WPW) syndrome was
revealed on a 12 lead electrocardiogram (ECG). Cardiology
team was consulted and further work up included serial
ECG's. As advised by the cardiology team, risperidone was
discontinued and the chest pain resolved with QTc interval
returning back to normal limits with no signs of WPW. Due
to potential risk of QTc prolongation, aripiprazole was
started and titrated to 10 mg PO daily. Patient's active
psychosis eventually subsided and was safely discharged
back to home. Discussion: This case presentation reenforces the importance of monitoring QTc with serial ECG's
in patients prescribed antipsychotic medications. Cardiac
arrhythmia such as torsade de pointes is well documented in
the literature that results from the use of antipsychotics.
Patients with known WPW that require treatment with
antipsychotics should be especially be closely monitored by
serial ECG's. Kuan-Pin Su5 reported an association of
olanzapine prolonging the QTc in WPW syndrome patient.
Aside from torsade de points, the literature rarely addresses
other cardiac arrhythmias associated with the use of
P4-21
MANAGING AGGRESSION, PREVENTING VIOLENCE: A
COMPREHENSIVE APPROACH IN AN ACUTE CARE
HOSPITAL
Lead Author: David G Folks, M.D., M.S.
Co-Author(s): Alexander de Nesnera, M.D.; Diane E. Allen,
RN, BSN
SUMMARY: New Hampshire Hospital is a state-run, acute
care psychiatric hospital with 160 beds serving adults,
adolescents, and children. Most referrals involve involuntary
admissions including court ordered or guardian approved
admissions. Approximately 60 percent of admissions
represent patients who are a danger to self or others with
many cases involving patients with impulsive aggression,
self-harming behaviors, or risk for violence. Over the past
decade, the hospital administration has worked with nursing
and medical staff leadership to develop a comprehensive
approach to aggressive behavior. Clinical staff receive an
extensive orientation and ongoing training workshops
focusing on the management of aggressive patients and
violence prevention. The protocols and programs are applied
before, during and after an episode of aggressive behavior.
Patients exhibiting hostility, anger, anxiety, tension, motor
agitation, or excitability are addressed with nonpharmacologic approaches as well as offering prn medications when clinically indicated. Hospital staff are skilled in
the application of the following programs, protocols and
services: Non Violent Crisis Management; The Staying Safe
Protocol; Personal Safety Emergency Procedures (code grey);
Seclusion and Restraint; and, Active Observation Levels.
Seclusion or restraint is utilized in keeping with APA and
Joint Commission guidelines. Moreover, a peer support
group, using evidence-based techniques responds to staff
that experience an assault in the workplace with a positive
impact on morale and productivity. Law enforcement
personnel from New Hampshire Department of Safety (State
Troopers) are available when a situation becomes unmanageable; the nurse in charge decides when law enforcement
takes over. All on-site law enforcement professionals are
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
presents an ambiguous vignette about a patient whose
symptoms could be interpreted as either psychiatric or
cardiac in nature. Respondents were randomized into three
groups, with each group being told that the patient presents
to a particular office: psychiatry, cardiology, or internal
medicine. The respondents were asked to identify the
patient's most likely diagnosis and most appropriate next
step in management, and then their attitudes toward the
patient were assessed using the Medical Condition Regard
Scale (MCRS). Analysis will be carried out to determine if
medical students hold psychiatric patients in lower regard
than medical patients, if attitudes toward psychiatric
patients change throughout the course of medical school,
and if students' experience during the psychiatry clerkship
affects their attitudes toward psychiatric patients.
trained as mental health workers with resultant skills in deescalation, avoiding injury to staff, other patients, or the
patient themself. High profile and high risk patients are
identified and receive oversight from an Administrative
Review Committee (ARC) focusing on risk management with
consideration of supervision, discharge planning, and
disposition. The ARC involves hospital legal counsel and
hospital administration together with the attending clinician
and assigned social worker. An analysis of violent episodes
with and without assault have shown a measureable reduction in violent acts with the implementation of these
programs and protocols. Personal Safety Emergencies have
increased, suggesting that staff are taking action sooner
when the risk for violence is imminent. This presentation will
provide data with regard to reductions in escalation of
aggressive behaviors; assaults with and without injury;
violent episodes, and the proportional increase in the use of
safety emergencies (code grey), peer support, and other
techniques to address violence and aggressive behaviors in
the hospital setting.
P4-24
RESTRAINT USAGE AND PATTERNS DURING 2010-2013 IN
A LARGE STATE HOSPITAL SYSTEM
Lead Author: Charles Broderick, Ph.D.
Co-Author(s): Rebecca Kornbluh, M.D.; Katherine Warburton,
DO
SUMMARY: A growing literature supports minimizing the
use of physical restraint in psychiatric hospitals. To better
understand the use of restraints in the California
Department of State Hospitals (which primarily serves a
forensic population), data on restraint episodes were
analyzed. During the years 2010-2013, there were 13,228
unique patients treated by DSH; 11,552 were first-time
admissions and 1,676 were repeat admissions. During this
period, there were 5,839 episodes of restraint recorded
involving 2,142 unique patients; median length of a restraint
episode was 2.17 hours. Re-admission was associated with a
higher rate of restraint than first-time admission (odds ratio
= 2.37, 95% CI = [2.07, 2.64]). Among those re-admitted,
women were restrained at a higher rate then men (odds ratio
= 1.60, 95% C.I. = [1.26, 2.038]), but there was no difference
between men and women among first admissions. Regarding
race, ethnicity and age, the only significant finding was that
Hispanics under 30 were restrained at a lower rate than
Whites or African Americans under 30 (odds ratio = 0.74, 95%
C.I. = [ 0.56, 0.98]). This was also true for Hispanics aged 30 to
40 when compared to Whites and African Americans aged
30-40 (odds ratio = 0.75, 95% C.I. = [0.57, 0.97]). Patients
diagnosed with Antisocial Personality Disorder (APD) when
admitted were more likely to be restrained (odds ratio = 1.49,
95 % C.I. = [1.27, 1.75]), and those patients with any Axis II
disorder were more likely to be restrained (odds ratio = 1.55,
95 % C.I. = [1.38, 1.74]). Similarly, those re-admissions with a
diagnosis of APD were more likely to be restrained (odds
ratio = 1.78, 95 % C.I. = [1.33, 2.38]), and those with any Axis
II disorder were more likely to be restrained (odds ratio =
2.36, 95 % C.I. = [1.87, 2.99]). Perhaps the most significant
finding was that patients were more likely to be restrained if
they had an act or multiple acts of physical violence. Of the
1519 new admissions who were restrained 1482 had one or
more incidents of violence (restrained group median=5
violent assaults, mean=10.74; non-restrained group median
=0 violent assaults, mean=1.049), yielding a finding of
significance (odds ratio = 94.62, 95% C.I. = [68.09, 131.48]).
Similarly, readmitted patients were also more likely to be
restrained if they had an act of physical violen (odds ratio =
95.59, 95% C.I. = [ 44.91, 203.48]. In summary, patients were
more likely to be restrained in DSH if they were violent, a
readmission, or a female re-admission. Hispanics were less
P4-22
PHYSICIAN ASSISTED SUICIDE FOR PSYCHIATRIC
PATIENTS IN THE NETHERLANDS A BRIDGE TOO FAR
FOR THE US?
Lead Author: René Cornelis Antonius de Veen, M.D.
Co-Author(s): S. van der Meer, MD
SUMMARY: Many severely psychiatrically ill patients suffer
immensely. One of our main concerns as doctors and
psychiatrists is to diminish that suffering. It is not uncommon that our patients suffer so much that they cannot bear
their pain anymore. Some take their own life. Some of them
do that in deep grief, some calmly determined, most of them
out of sheer hopelesness. It is our professional position in
the Netherlands that we do not want to abandon our
patients, often after we have shared their (life)long struggle
with their illness. We feel we need to help them, even in this
stage of their illness. In the Netherlands a law on euthanasia
offers patients and their doctors an opportunity to engage in
a process that can lead to assisted suicide by the patient. This
process is safegarderd by thorough and intense procedures
to make sure that the provided assistence with the suicide is
in accordance with law and ethics. The poster that will be
presented does supply data on suicide rates in the Netherlands and the USA and on the Dutch procedures, it that
sense it is informative. But its foremost goal is to be the
starting point of a discussion between us and our colleges
about this highly controversial but unavoidable subject.
Let's not turn our heads from this painfull matter.
P4-23
MEDICAL STUDENT ATTITUDES TOWARD MENTAL
ILLNESS AND ITS EFFECTS ON PATIENT MANAGEMENT
Lead Author: Rachel Tamaroff
Co-Author(s): Daniel Cukor, PhD
SUMMARY: It has been well-established that stigma against
mental illness is robust among medical professionals and
students. In addition, medical students demonstrate declining empathy as they progress through their training.
However, it is not known if or how this stigma, coupled with
declining empathy, affects the attitudes toward and management of mentally ill patients. In this study we will assess
medical student attitudes toward psychiatric and medical
patients. An online survey was sent to all medical students
enrolled at an urban medical center in New York. The survey
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AMERICAN PSYCHIATRIC ASSOCIATION
P4-26
ANTIDEPRESSIVE TREATMENTS FOR PARKINSON’S
DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS
Lead Author: Emily Bomasang-Layno, M.D., M.Sc.
Co-Author(s): Iris Fadlon, M.D.; Andrea N. Murray, M.D.; Seth
Himelhoch, M.D., MPH
SUMMARY: Background/Objectives: Depression affects 50
to 70% of Parkinson's disease patients resulting in significant
comorbidity, executive dysfunction, and poorer quality of
life. Different modalities have resulted in variable results
precluding distinct recommendations for treatment. Our
objective is to perform a systematic review and metaanalysis of published randomized controlled trials (RCTs)
evaluating the efficacy of pharmacologic and behavioral
methods, and repetitive transcranial magnetic stimulation
(rTMS) for depression in idiopathic Parkinson's disease.
Methods: The following databases were searched: PubMed,
CINAHL, EMBASE, and PsycInfo, as well as the trials
registers, ClinicalTrials.gov and the Cochrane Central
Register. Bibliographies of relevant articles were also crossreferenced. This review included RCTs that compared
pharmacologic and behavioral methods, or rTMS with a
placebo or with other drugs or methods, with no restrictions
on participant age, gender, and duration or setting of
treatment. Eligibility assessment was performed independently in an unblinded standardized manner. Identified
records were sequentially screened according to eligibility
criteria with full texts subsequently reviewed. Disagreement
after full text review was resolved by consensus and a third
reviewer. Differences in mean depression score and 95%
confidence intervals were calculated. Results: A total of 893
idiopathic Parkinson's disease patients with clinical depresssion across 20 RCTs were included in the analysis. The
overall standard mean difference for all pharmacologic
interventions was 0.30 (95% CI -0.00, 0.61, p=0.054). On
stratification of pharmacologic treatments, however, there
was a distinct difference in effect between antidepressants,
specifically SSRIs and TCAs, (SMD of 0.54, 95% CI 0.24, 0.83,
p=0.000), and non-antidepressant medications (SMD of 0.29, 95% CI -0.86, 0.29, p=0.328). Behavioral interventions
demonstrated significant efficacy with an effect size of 0.86
(95% CI 0.4, 1.32, p=0.000), with CBT contributing the largest
effect. Conclusions: Both antidepressants, specifically SSRIs,
and behavioral interventions, specifically CBT, significantly
improved depression among Parkinson's disease patients.
rTMS is also a promising form of treatment.
likely to be restrained than other similarly-aged patients. In
this forensic population, violence reduction and restraint
reduction are likely inter-related efforts. Future efforts at
violence reduction will be analyzed for impact on restraints,
and demographic/diagnostic factors will be evaluated to see
if identification of patients at high risk for restraint can be
developed.
P4-25
CITALOPRAM-INDUCED SEIZURE IN AN ADOLESCENT
Lead Author: Sarah Ventre
Co-Author(s): Rachelle St. Onge; Adekola Alao, MD
SUMMARY: Introduction Approximately 3.2 percent of
adolescents use antidepressants. Selective serotonin reuptake inhibitors (SSRIs) have become the most frequently
prescribed medication in the treatment of depression due to
their relatively safe side effect profile (1). The mechanism of
action among all SSRIs is the specific inhibition of serotonin
reuptake in the presynaptic membrane of neurons. Despite
the higher safety margin among SSRIs, adverse effects at
increased doses include dizziness, sweating, nausea,
vomiting, tremor, somnolence, and sinus tachycardia due to
excess serotonergic stimulation, which may also cause
serotonin syndrome. Of the SSRIs, citalopram has been
associated with a greater risk of seizure, as well as QT
complex prolongation (1). To the best of our knowledge, this
is the first reported case of citalopram-induced seizure in an
adolescent. Case Report The patient is a 14-year-old
Caucasian male who has a history of Major Depressive
Disorder. He presented to the emergency department after
overdosing on 15 tablets of Citalopram 20mg (total of
300mg). For the past year he had been treated for depression
by his primary care physician with citalopram 20mg PO daily
and was stable, without any adverse drug effects. He was not
on any other medications and had no other past medical
history, including seizure. A psychiatry consult was performed to evaluate for persistent suicidal ideation. During
the interview, the patient experienced a generalized epileptic
seizure. Versed 2 mg was given intravenously, and the
patient was transferred to the intensive care unit, where he
was stabilized and later discharged. The citalopram was
discontinued and the patient was referred for psychotherapy. Discussion and Conclusion Although there are
many reports of citalopram causing seizures in adults, the
majority of cases are at doses well above 600 mg and there
are no reported cases of citalopram-induced seizure in
adolescents. This report highlights a case of citalopraminduced seizure in a 14 year-old patient at the dose of 300
mg, suggesting that, although rare, citalopram can indeed
cause seizure in adolescents at a lower dose. Additional case
reports in the future may allow us to further narrow the
threshold warranting concern for seizure among adolescents. In the interim, physicians should remain aware that
overdose of citalopram, and perhaps other SSRIs, in
adolescents, can result in seizure in the acute setting.
Therefore, patients should be medically stabilized before
considering
post-overdose
psychiatric
consultation.
Reference
P4-27
CLOZAPINE DISPENSING AND USAGE TRENDS IN
QUEENSLAND
Lead Author: Dan Siskind, M.B.B.S., M.P.H., Ph.D.
Co-Author(s): Tori Forrester, Sam Hollingworth, Amanda
Wheeler, Karl Winckel
SUMMARY: Background Clozapine is well established as the
most clinically effective therapy for people with treatmentresistant schizophrenia supported by guidelines from NICE,
RANZCP and others. Clozapine usage in this consumer
group has previously been low. This is likely associated with
concerns of serious adverse drug reactions (ADR) in particular blood dyscrasias, although more recently gastric and
cardiac ADRs have been identified as a major concern.
Methods The aim was to examine clozapine use within
Queensland over the last 10 years and to analyze reported
ADRs. Data was extracted from statewide hospital pharmacy
dispensing records. Correlations between increased use and
1. Fitzgerald, K. T., & Bronstein, A. C. (2013). Selective serotonin reuptake
inhibitor exposure. Topics in Companion Animal Medicine, 28(1), 13-17.
doi:10.1053/j.tcam.2013.03.003; 10.1053/j.tcam.2013.03.003
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
mental health legal status, electroconvulsive therapy,
problems with activities of daily living, community contacts.
ADRs will be investigated. The ramification of increased
clozapine use in terms of safe and quality use will be
discussed Results Clozapine dispensing increased 71% from
2004 to 2012. Concomitantly there was a 770% increase in
the number of documented serious ADRs; 7 in 2004 to 61 in
2012. This included 23 cardiac ADRs in 2012 compared to
only one in 2004. Whilst this increased use of clozapine may
be appropriate, the increase in reported ADRs, including
cardiac ADRs, is concerning. Careful consideration of
resourcing of monitoring and management systems, as well
as development, acceptance, standardisation and resourcing
of monitoring guidance is required. We will present feasible
recommendations. Conclusions Clozapine usage and
reported ADRs has increased significantly over the last
decade. The potential for adverse outcomes associated with
this gold-standard treatment should be considered by
clinicians and service managers alike. Robust monitoring,
management and reporting systems for ADRs are required
P4-29
MENTAL HEALTH POPULATION STUDY: A
RETROSPECTIVE REVIEW OF THE INCIDENCE OF
PRESCRIBED ANTIPSYCHOTIC MEDICATIONS AND
OTHER SUBSTANCES DETECTED IN URINE
Lead Author: Mancia Ko, Pharm.D.
Co-Author(s): RA Millet, Jr., MD, M Ko, PharmD, MBA, P
Woster, PharmD, M DeGeorge, PharmD, and K Bronstein,
PhD, RN
SUMMARY: Background: Prior research has established the
critical role of maintenance antipsychotic drugs (APD) in the
management of patients with serious mental illness in
preventing relapse, and that approximately 50% of seriously
mentally ill patients are not adherent to their prescription
regimen.1,2,3 In addition, the presence of concurrent
substance abuse can also play a part in contributing to
medication non-adherence. Objective: The purpose of this
study was to identify potential non-adherence rates among
patients on APD therapy and to determine if differences in
urine drug testing (UDT) results exist between APD positive
and APD negative patients. Methods: Between April 15, 2013
to January 29, 2014, 3331 urine samples were obtained from
patients prescribed APD. Samples were classified as APD
positive (a positive LC/MS/MS result for APD parent and/or
metabolite) or APD negative (negative LC/MS/MS). Samples
were also classified as positive or negative for the following:
non-prescribed opiate medications, non-prescribed synthetic opioids, cocaine and THC. Results: The study
population was 45.8% male and had a mean age of 43.1 ±
13.0 years. The geographic distribution was 83.1% South,
10.3% Midwest, 5.9% North and 0.7% West. UDT was
positive for APD in 76.4% of samples and negative in 23.6%.
APD negative individuals were more likely than APD positive
to have a non-prescribed opiate found (16.4% vs 13.1%; OR
1.30; 95% CI, 1.05-1.63), a non-prescribed synthetic opiate
found (6.0% vs 2.6%; OR 2.35; 95% CI, 1.61-3.45), have THC
found (20.7% vs 17.3%; OR 1.25; 95% CI, 1.02-1.53), or have
cocaine found (8.6% vs 4.2 %; OR 2.12; 95% CI, 1.55- 2.91).
Approximately 6% of all the samples had a non-prescribed
APD (either parent or metabolite) found. In this group, 6%
had both the prescribed APD present and an additional nonprescribed APD, and 6% of the samples were missing the
prescribed APD with a different APD found. Conclusions:
These data suggest that UDT in patients who are prescribed
APD can be of value in both monitoring adherence to APD
therapy, and in identifying the use of inappropriate
prescription and non-prescription substances. The data also
suggests that non-adherence to prescribed APD therapy is
associated with use of non-prescribed opioids, marijuana,
and cocaine. References:
P4-28
PREDICTORS OF MENTAL HEALTH-RELATED ACUTE
SERVICE UTILISATION AND TREATMENT COSTS IN THE
TWELVE MONTHS FOLLOWING ACUTE PSYCHIATRIC
ADMISSION
Lead Author: Dan Siskind, M.B.B.S., M.P.H., Ph.D.
Co-Author(s): Sandra Diminic; Georgia Carstensen; Gail
Robinson; Harvey Whiteford
SUMMARY: Objective: A key step in informing mental health
resource allocation is to identify predictors of mental healthrelated service utilisation and treatment costs. This project
aims to identify predictors of mental health-related acute
service utilisation and costs in the year following an acute
public psychiatric hospital admission. Method: A dataset
containing administrative and routinely measured outcome
data for one year before and after an acute psychiatric
admission for 1757 public mental health patients was
analysed. Multivariate regression models were developed to
identify patient- and treatment-related predictors of four
measures of service utilisation or cost: (1) length of index
admission; and, in the year after discharge from the index
admission, (2) psychiatric bed days; (3) emergency department (ED) presentations, and; (4) total acute mental health
service costs. A split-sample cross-validation approach was
used. Results: With respect to the index admission, a diagnosis of psychosis, problems with living conditions and prior
psychiatric bed days predicted longer length of stay, while
prior ED presentations and self harm predicted shorter
length of stay. Greater number of bed days in the year postdischarge was predicted by psychosis diagnosis, problems
with living conditions and prior psychiatric hospitalization.
Number of future ED presentations was predicted by past ED
presentations. For total acute care costs, diagnosis was the
strongest predictor. Illness acuity and prior hospitalization
also predicted higher costs, while self-harm predicted lower
costs. Discussion: The development of effective models for
predicting acute mental health treatment costs using existing
administrative data is an essential step towards a workable
activity based funding model for mental health. Future
studies would benefit from the inclusion of a wider range of
variables, including ethnicity, clinical complexity, cognition,
1. Velligan, DI, et al. The expert consensus guideline series: Adherence
problems in patients with serious and persistent mental illness. J Clin
Psychiatry. 2009;70[suppl 4]:1-48.
2. Copeland LA, Zeber JE, Salloum IM, et al. Treatment adherence and
illness insight in veterans with bipolar disorder. J Nerv Ment Dis.
2008;196:16-21.
3. Byerly MJ, Thompson A, Carmody T, et al. Validity of electronically
monitored medication adherence and conventional adherence measures
in schizophrenia. Psychiatr Serv. 2007;58:844-847.
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AMERICAN PSYCHIATRIC ASSOCIATION
P4-31
TO COMPARE THE ABUSE POTENTIAL OF OXYCODONE
IN HEALTHY POPULATION AND SUBSTANCE USERS BY
SYSTEMATIC REVIEW
Lead Author: Muhammad Rizvi, M.D.
Co-Author(s): Evaristo Akerele, MD
SUMMARY: Background: Prescription drug overdose is now
the leading cause of accidental death in the United States
(US) surpassing motor vehicle accidents in 2012 (Goodlett et
al 2012). In the last two decades, the misuse and abuse of
prescription opioids grew at exponential rates partly due to
aggressive pain treatment with prescription opioid analgesics ( Lembke A et al 2012). In 2007, there was one
accidental drug overdose death every 19 minutes. The
numbers of opioid analgesic-related overdose deaths have
exceeded that of cocaine and heroin combined (CDC:
prescription drug overdoses (US Epidemic, 2012). Oxycodone (dihydrodydroxycodienone), full mu opioid agonist ,is
a semi-synthetic opioid that has been in clinical use for more
than 90 years.(Beaveret al., 1978). Historically, oxycodone
was considered to be associated with a lower abuse liability,
similar to that of codeine, because it was initially introduced
to the United States in 1981 in combination with over-thecounter non-opioid analgesics (Poyhia et al., 1993). At a
national level, hydrocodone and oxycodone are the most
frequently prescribed opioid analgesics and have the highest
level of abuse of any prescription medication. [IMS, The use
of medicines in the United States, 2011]. Despite the associated morbidity and mortality related to prescription opioid
use and seriousness of the problem, relatively few studies
have examined the abuse potential of oxycodone and limited
data available on abuse potential of oxycodone in healthy
individual in comparison with substance users. Methods: A
search of PUBMED, EMBASE and MEDLINE databases
between years 2000 and 2013, identified articles that describe
the likeability and or abuse potential of oxycodone in healthy
population and patients with history of substance abuse. We
identified 10 double blind randomized controlled trials.
Among them 6 trials were done on patient with a history of
substance abusers and 4 trials were done on healthy subjects
with no history of drug abuse. After an assessment of study
quality relevant data such as demographics, study design,
outcome measures, results and funding source were
compiled into evidence tables of oxycodone use in healthy
population and substance abusers. Results:. The abuse
liability or potential of oxycodone were found similar across
both the comparison groups. Conclusion: In future, further
randomized double blind trials comparing oxycodone abuse
potential in healthy and substance users needs to be done
with large sample size to replicate the findings.
P4-30
INTERVENTIONS TO IMPROVE HOSPITAL CONSUMER
ASSESSMENT OF HEALTHCARE PROVIDERS & SYSTEMS
BY TRAINING STAFF MEMBERS WITH EFFECTIVE
COMMUNICATION SKILLS
Lead Author: Muhammad Rizvi, M.D.
Co-Author(s): Ebone M. Carrington MPA, Stuart Aaronson
LCSW-R, Evaristo Akerele MD, Zafar Sharif, MD
SUMMARY: Background: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), is a
standardized survey developed and mandated by the Centers
for Medicare and Medicaid Services (CMS) to measure
hospital experience by patients on ten measures of care. The
public reporting initiative not only affects hospital reputetion and standing in the community, it also serves as the
basis for financial payments. Of the 21 patient perspective
questions on the survey, 9 of them involve communication.
The Joint Commission for Accreditation of Health Care
Organizations (TJC) has noted, "Physicians are most often
sued, not for bad care, but inept communication" (2005). A
2003 study by JCAHO documented that communication
breakdown was the root cause of more than 60% of 2,034
medical errors, of which 75% resulted in the patient's death
(COPIC, 2005). In other words, 915 people died as a result of
a communication error. AIDET is an effective communication tool developed by Studer Group to improve patient
satisfaction and enhance financial outcomes in health care
systems.(www.studergroup.com). Methodology: First phase:
Staff members from each service s were selected on the basis
of merit and trained as master trainers for effective
communications skills with AIDET/CARES: A: Acknowledgment: I: Introduction; Duration: E: Explanation: Thank you,
while simultaneously re introducing our values and standards of behavior including, CARES: C; Consistent, A:
Accountable, R: Respectful, E: Excellent; S: Safe. Second
phase: The hospital's around 2190+ employees are distributed into 10 working groups of 44 AIDET master trainers.
The AIDET master trainers from each service are training
other staff members with effective communication skills.
Third phase: The working groups will constantly monitor the
implementation and consistent utilization of effective
communications techniques by the trained staff members in
their everyday communication with patients and other staff
members. Results: The data obtained from Press Ganey,
HCAHPS summary report, surveys returned till January 15,
2014, Pre-Intervention 3Q2013 (N=212) and Post Intervention 4Q2013 (N=136), Harlem Hospital Center, including
department of Medicine, Psychiatry, Surgery, OB GYN and
ICU. The utilization of AIDET/CARES as an effective
communications tools has resulted in improvement in all
domains of HCAHPS survey in 4Q2013 as compare to
3Q2013. Conclusions: Consistent utilization and implementtation monitoring of AIDET/CARES is critical to sustain and
enhance patient satisfaction. In future, the model/strategy
use to improve HCAHPS scores in Harlem Hospital Center
can be applied at other facilities in Health and Hospital
Corporation.
P4-32
THE EFFECTS OF STRESS COPING STRATEGIES ON POSTTRAUMATIC STRESS SYMPTOMS IN CIVIL AFFAIRS
OFFICIALS
Lead Author: Minyoung Sim, M.D.
Co-Author(s): Ji-ae Kim, Kyung-ah Jeung, Myung-Ja Oh,
Joonho Na
SUMMARY: Aims We aimed to evaluate the level of posttraumatic stress and depressive symptoms in civil affairs
officials. The relationships between post-traumatic stress
and depressive symptoms, and stress coping strategies were
also analyzed in the study Methods Total 83 civil affairs
officials (54 men, 38.9±8.9 yrs) participated and completed
questionnaires to assess post-traumatic stress symptoms
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(PTSS)(Impact of Event Scale-Revised, IES-R), depression
(Beck Depression Inventory, BDI), anxiety (Beck Anxiety
Inventory, BAI), suicide idea (Scale for Suicidal Ideation, SSI)
and coping strategies (Ways of Coping Checklist). The coping
strategies divided into 4 dimensions of problem-focused,
social support seeking, emotion-focused, wishful thinking.
Problem-focused and social support seeking were active
coping type and emotion-focused and wishful thinking were
passive coping type. Results Among 83 subjects, 40 and 16
subjects showed significant PTSS and depressive symptoms
(48.2% and 19.3%). The primary coping strategies was wishful thinking (mean scores: 1.65±0.50), followed by problemfocused (mean scores: 1.63±0.47), social support seeking
(mean scores: 1.43±0.53), emotion-focused (mean scores:
1.39±0.35). Active coping group (n=44, 53.1%; more using
problem-focused and social support seeking) had lower
avoidance, lower BDI, lower BAI, and lower SSI scores than
passive coping group (F=4.7, p=.03; F=13.4, p<.001; F=5.20,
p=.02, F=12.5, p<.001, respectively). Emotion-focused scores
were positively correlated with scores of avoidance,
hyperarousal, total IES-R, and BAI after controlling age and
sex effects (r=.27, p=.03; r=.28, p=.03; r=.26, p=.04; r=.31,
p=.01, respectively). Conclusions Civil affairs officials
showed higher level of PTSS and depressive symptoms. The
stress management program with adjustment of coping
strategies could be expected to handle their mental health
problems.
testing, most inpatients were not tested, indicating need for
additional intervention strategies.
P4-34
CHANGES IN COGNITION IN RESPONSE TO DEPRESSION
TREATMENT DURING INPATIENT PSYCHIATRIC
HOSPITALIZATION
Lead Author: Luba Leontieva, M.D., Ph.D.
Co-Author(s): Sergey Golovko, MD, PhD, Aadhar Adhlakha,
MD, Lyuba Polinkovski, MS3, Charles Harris, MD, Donald A.
Cibula, PhD, Thomas Schwartz, MD, and James L Megna MD,
PhD
SUMMARY: The goal was to investigate whether depressed
patients' cognition changed depending on treatment with
SSRIs vs. SNRIs during an inpatient stay. Participants were
119 depressed inpatients, average age 39 years, 61% females,
77% Caucasian, 74% with mood disorders, 50% Cluster B
traits/disorders,and 32% psychoactive substance abusers.
Measures: Trail Making Test (TMT)A, Hamilton Depression
Rating Scale (HDRS), and Outcome Questionnaire-45(OQ45). Results: paired t-tests comparing patients' performance
at admission (A) and discharge (D) revealed significant
differences in HDRS scores (MA = 24, MD = 9, t(98) = 25.30, p
<.001), and OQ-45scores (MA = 105, MD = 72, t(97) = 12.91, p
< 0.001). Baseline-adjusted mean TMT A scores at discharge
were 43.65 sec. (SD = 3.28 sec, n = 72) for the SSRI group and
33.40 sec. (SD = 3.92, n=50) for the SNRI group (t(120) = 2.00,
p=.047 . Conclusions: patients' cognition improved as their
depression lifted during an inpatient stay. SNRIs may
preferentially produce such an effect versus SSRIs. Their
functioning improved concomitantly.
P4-33
INCREASING HIV TESTING IN INPATIENT PSYCHIATRY
Lead Author: Martha Shumway, Ph.D.
Co-Author(s): Christina Mangurian, MD, Noah Carraher, MA,
Amanda Momenzadeh, James W. Dilley, MD
SUMMARY: Objective: Persons with serious mental illness
have elevated rates of HIV infection, yet have low rates of
HIV testing. Inpatient psychiatric hospitalizations provide
underutilized opportunities for testing. This study evaluated
interventions to increase HIV testing in an urban, publicsector inpatient psychiatry service between 2006 and 2012.
Three interventions of varying intensity and duration were
implemented. In 2008, an administrative champion began
advocating for testing and an HIV test counselor was
assigned to the inpatient service for one year. In 2010, a
clinical champion began to promote testing. Methods:
Electronic medical record data were analyzed for patients
admitted to inpatient psychiatry between 2006 and 2012 who
had not previously been identified as HIV-positive. General
estimating equation models were used to evaluate testing
rates over time and whether testing was associated with
patient characteristics. Findings: There were 13,802 eligible
admissions. Patients' mean age was 42. 64% were male. The
diverse sample was 27% African American, 14% Asian, 10%
Latino, and 42% white. Mean length of stay was 11 days.
Prior to intervention, 6% of patients were tested for HIV. In
2009, following arrival of the administrative champion and
one year of dedicated HIV test counseling, 23% were tested
(z=16.01, p<.0001). Following arrival of the clinical champion, this testing rate was sustained for two years without
dedicated counseling and increased to 30% in 2012 (z=4.00,
p<.0001). Patients who were older, African American, and
hospitalized for fewer days were less likely to be tested
(p<.05). Impact: A temporary, intensive intervention significantly increased HIV testing on an inpatient psychiatry
service. Increases were sustained with ongoing administrative and clinical advocacy. Despite increases in HIV
P4-35
CLINICAL UTILITY AND PRELIMINARY OUTCOMES OF
TWO MEASURES ASSESSING DAILY FUNCTIONING AND
ASPIRATIONS OF YOUNG PEOPLE WITH FIRST EPISODE
PYCHOSIS
Lead Author: Heleen Loohuis, M.Sc.
Co-Author(s): A Malla, M Pope, N Pawliuk, S Iyer
SUMMARY: Introduction: Assessing daily activities, functioning and future aspirations is clinically important to assist
first episode psychosis (FEP) patients in reaching their goals.
The aim of this study is to assess the clinical utility of two
self-reports that evaluate daily functioning and current and
future aspirations of FEP patients. Method: These self-report
measures are administered at various points during followup at the Prevention and the Early Intervention Program for
Psychosis (PEPP) in Montréal, Canada. The first is the
Social Functioning Scale (Birchwood et al.,1990) with minor
modifications, which assesses three domains: pro-social
activities (e.g., going out to bars, visit a museum), activities
that demonstrate independence and competence (e.g.,
cooking and cleaning the house) and recreational activities
(e.g., playing video games, playing an instrument). The
second, 'Activities Self-Report', assesses current functioning
and aspirations as well as satisfaction with one's daily
activities, self-rated performance in these activities, perceived importance of these activities, and future aspirations.
Results: Preliminary analyses was conducted on these two
self-reports completed at baseline (N=33). Four (12%)
patients reported that their main activity was either work or
school; however, most respondents reported something else
(e.g., playing videogames, taking care of health) as their main
activity. Nineteen respondents (59%) reported that they
would like to be full-time in school or working at the
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frequent emergency room and clinic visits. Careful history
revealed that the presentation of the spells was atypical
compared to her usual episodes characterized by head
shaking, confusion, electrical sensation in the head, and
periods of whole body shaking with no postictal state. She
was admitted in our epilepsy monitoring unit and intensive
video EEG monitoring was performed for four days. We were
able to capture all her spells, which did not reveal any
electrographic seizures. The diagnosis of psychogenic nonepileptic seizures (formerly known as pseudoseizures) was
made with follow up with psychiatry. Our case report
emphasizes the importance of intensive video EEG
monitoring in patients with well-established diagnosis of
epilepsy. Thus, this case illustrates the importance of
intensive video EEG monitoring as a helpful diagnostic tool
in patients with a new onset of atypical events with
increasing frequency and frequent emergency department
admissions, clinic visits, and hospital admissions.
moment. Twenty (62%) respondents reported that they were
less engaged in their main activity than they would like; 11
(35%) respondents were dissatisfied with their main activity;
7 (23%) were neither dissatisfied nor satisfied; and 13
patients (42%) were somewhat satisfied with their main
activity. Respondents' current aspirations were discrepant
from their future aspirations (i.e., their aspirations in 5
years). Further analyses with a larger sample size and
including self-reports completed later during follow-up will
also be presented. Conclusions: These two measures collect
rich and clinically relevant information on daily activities,
functioning, and life aspirations which may not be captured
in clinical sessions with FEP patients. They could thus be
valuable tools for clinicians.
P4-36
INTEGRATION OF PSYCHIATRIC SERVICES INTO A
PRIMARY CARE, HOMELESS SERVICES CLINIC: SYSTEMWIDE EFFECTS AND IMPLICATIONS FOR RESIDENCY
TRAINING
Lead Author: Jeffrey C. Eisen, M.B.A., M.D.
Co-Author(s): Marshall Forstein, M.D.; Mark McGovern,
L.I.C.S.W.
SUMMARY: A well-established primary care clinic, dedicated
to the medical care of the homeless and housing unstable
population in the catchment area of the Harvard Medical
School affiliated Cambridge Health Alliance (CHA), identified that a significant number of their patients faced comorbid psychiatric and substance use concerns, and that
many of these patients utilized CHA acute services for
treatment of psychiatric and substance-related concerns. A
dialogue began between clinicians at this site and a member
of the CHA Department of Psychiatry, who initiated a plan to
integrate psychiatric services into this clinic. A diverse set of
patient, system, and residency-training based objectives
were identified, and the team faced challenges across each of
these parameters in operationalizing the integrated service.
This poster documents the identification of the opportunities; the barriers encountered during the both the implementtation and patient care phases of program development; the initial results that supported continuation of the
service, which has served as a model for additional primary
care—psychiatry integration initiatives; and the implications
for resident leadership and training.
P4-38
EXAMINING PERCEPTIONS OF ACADEMIC STRESS AND
ITS SOURCES AMONG UNIVERSITY STUDENTS: THE
PERCEPTION OF ACADEMIC STRESS SCALE (PAS)
Lead Author: Dalia Bedewy, Ph.D.
Co-Author(s): Adel Gabriel
SUMMARY: INTRODUCTION: Evaluating perceptions towards academic stress and its sources, among undergraduate university students might allow programmatic
changes designed to enhance students' psychosocial wellbeing and academic performance. OBJECTIVES: The objecttive of this study was to examine the perceived academic
stress and its sources among undergraduate university
students. METHOD: Based on empirical evidence and recent
literature review and modification of a previously developed
survey we developed a 21 item scale to measure perceptions
of academic stress and its sources consisting of four
subscales; 1) Perceptions of self-efficacy subscale, and 2)
Perceptions of faculty and administration subscale; 3)
Perceptions of workload subscale; and 4) Performance
pressures subscale. Experts (n=10) participated in a
validation of the instrument before it was piloted in a
(n=100) volunteered postgraduate students, and then
administered to consenting students (n= 500). At the same
time students provided their demographics. RESULTS: The
face and content validity was examined and there was an
overall agreement between experts about the relevance of
the instruments' items to measure students' perceptions of
academic stress and its sources. Internal consistency
reliability for the instrument was 0. 65 (Cronbach's alpha)
and factor analysis resulted in four significantly correlated,
and theoretically meaningful factors. The four factors
accounted for 41 % of the variance in responses related to
students' perceptions of academic stress and its sources.
There was evidence for convergent and discriminant validity.
CONCLUSION: we developed and tested a scale to measure
academic stress and its sources, with acceptable reliability,
and evidence for validity. This scale takes five minutes to
complete. Results from this project will be utilized to council
university students before and during taking high stakes
examinations.
P4-37
ACUTE ONSET OF PSYCHOGENIC NON-EPILEPTIC
SEIZURES IN A PATIENT WITH CHRONIC INTRACTABLE
EPILEPSY
Lead Author: Diana Robinson, M.D.
Co-Author(s): Batool Kirmani, MD
SUMMARY: We describe a case-report of a young female
with long-standing epilepsy since childhood. She has failed
three resective sugeries, anterior left temporal lobectomy,
complete total lobectomy, frontal resection, and most of anti
epileptic drugs available on the market including the vagal
nerve stimulator. She remains intractable with two to three
seizures per week on tiagabine, carbamazepine, and vagal
nerve stimulator. This was the best control for more than a
decade. She was seen in our epilepsy clinic with an increase
in seizure frequency ranging from 10-20 per day requiring
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P4-41
COMPETENCIES IN COLLABORATIVE MENTAL HEALTH
CARE: DEVELOPING A NORTH AMERICAN CONSENSUS
ON TRAINING FUTURE PSYCHIATRISTS
Lead Author: Nadiya Sunderji, M.D.
Co-Author(s): Andrea Waddell, MD MEd ; Mona Gupta, MD
PhD; Rosalie Steinberg, MD MPH; Sophie Soklaridis; Jon
Fleming, MD
SUMMARY: Background Competency-based medical education provides a critical framework for curriculum design that
ensures clarity, relevance and accountability for learners'
abilities at the end of training. To date, the accrediting
bodies for medical education in Canada and the United
States have not clearly specified the competencies required
for Collaborative Care practice. For example, the Royal
College of Physicians and Surgeons of Canada (RCPSC)
introduced a mandatory training requirement without
clearly defining Collaborative Care practices or objectives of
training, making it difficult to evaluate the appropriateness
of existing training opportunities. While limited literature
describing resident training experiences in Collaborative
Care exists, there is a need to understand competencies and
outcomes to guide future training. Method We are conducting a mixed methods study to develop a North American
expert consensus on the core competencies required for
Collaborative Care. We are holding in-depth interviews with
approximately 12-15 psychiatrists who provide Collaborative
Care with diverse practices, settings and populations
throughout Canada, and conducting a thematic analysis. We
are conducting a modified Delphi expert consensus process
with approximately 25-30 Collaborative Care and education
experts across North America, using a survey tool that is
based on the interviews and a review of the literature,
including a recent American manuscript suggesting
Collaborative Care competencies. Results In this poster we
present our findings to date, including key educational
themes and competencies identified by interviewees that
may have broad relevance. Furthermore, we describe how
the findings are being translated into educational practice
through a curriculum map at the University of Toronto. Eight
Collaborative Care psychiatrists who have participated in the
study work in varied settings, for example primary care
teams, nursing homes, child protection services, shelters,
jails, and rural communities. Preliminary results suggest that
Collaborative Care psychiatrists need to be able to: a)
address issues of power, leadership, and team dynamics, b)
capitalize on opportunities for knowledge translation
through case consultation and ongoing mentorship, c)
appreciate and tolerate risk outside of clinical settings, and
d) apply knowledge of the health systems and public policy
context toward helping other providers navigate services for
their patients/clients. DISCUSSION The findings to date
point to the range of abilities, beyond medical expertise, that
are required for competent practice of Collaborative Care, as
well as the variety of untapped training opportunities that
may exist in residency programs. A shared understanding of
the desired outcomes of Collaborative Care education will
strengthen pedagogical approaches to training, and
ultimately improve psychiatric workforce development for
evolving models of mental health service delivery.
P4-39
SOMETHING NEW? ADOLESCENT WITH FIRST
PSYCHOTIC BREAK AND FAMILIAL ADENOMATOUS
POLYPOSIS
Lead Author: Luisa S Gonzalez, M.D.
Co-Author(s): Jose Alfredo Alvarez M.D.; Erica Weinstein;
Panagiota Korenis M.D.
SUMMARY: Schizophrenia is associated with high mortality
and morbidity. The etiology of schizophrenia remains unclear, studies implicate a multifactorial origin with genetic
and environmental factors. The adenomatous polyposis coli
(APC) gene has been associated with Familial Adenomatous
Polyposis (FAP) and it has been linked to schizophrenia.
However, few studies examine the association between FAP
and schizophrenia. Limited data exists regarding recommendations for genetic counseling of adolescents with
comorbid psychiatric illness. A case of an adolescent with
FAP who developed psychotic symptoms is presented. This
case hopes to add to the literature about mental illness in
those with FAP. A review of literature about the role of APC in
schizophrenia as well as implications of genetic counseling
on those who suffer with mental illness will be discussed.
P4-40
DELIVERY AND TEACHING TELEPSYCHIATRY SERVICES
IN AN URBAN MENTAL HEALTH SYSTEM IN NEW YORK
CITY
Lead Author: Jose Vito, M.D.
Co-Author(s): Rubianna Vaughn, M.D., MPH; Hudson
Elmore, M.D.
SUMMARY: Telepsychiatry has been in use for many years;
however, as technology has improved, costs have decreased
and evidence has mounted to support its use, its role has
increasingly expanded. Research into telepsychiatry has
explored a wide range of potential uses, from child to
geriatric populations; from the emergency setting to home
consultations; and among a variety of ethnic groups. One of
the most widely used and researched applications of
telepsychiatry has been improving access to care for patients
often living in remote, rural settings. However, one novel use
explored in this article is that of fostering engagement with
the mental health system in an urban setting. One of the
highest-risk times for disengagement from care is immediately after discharge from the inpatient setting. Among the
successful strategies to improve engagement are "reaching
out" techniques, including having patients meet with
outpatient staff prior to discharge. As this is not always
feasible to do in person, telepsychiatry could provide a
potentially time-efficient means to foster engagement and
establish a rapport with patients prior to discharge with the
goal of improving rates of follow-up and reducing rehospitalizations. In this study, we looked at the effect of
videolink interviews conducted over a five months period
prior to discharge from the inpatient setting on the rates of
follow-up and re-hospitalization. All interviews in this study
were conducted by psychiatry trainees with attending
supervision, which points to the potential educational
benefits of this technology and provides residents with
experience in using a technology whose use is likely to grow
in the coming years.
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P4-43
CONFIRMATION OF RELIGIOSITY AS A PROTECTIVE
FACTOR AGAINST SUICIDALITY WITHIN A PSYCHIATRIC
INPATIENT SAMPLE BY USING C-SSRS
Lead Author: Amanda White, B.S. Co-Authors: Alan J.
Gelenberg, M.D., Ahmad Hameed, M.D., Roger E. Meyer,
M.D., Michael A. Mitchell, M.A., Eric A. Youngstrom, Ph.D
SUMMARY: Introduction: Religious involvement is associated with fewer negative mental health outcomes including
suicidality. Suicidal behavior is more common among those
who do not consider themselves as religious and do not have
moral objections to suicide. However, few studies have
examined suicidal ideation and have used a standardized
suicide assessment instrument such as the Columbia Suicide
Severity Rating Scale (C-SSRS) to study the effect of religion
on suicidality. Method: Data were collected and analyzed as
part of an original study comparing suicide assessment
instruments in adult psychiatric inpatients (n = 199). The CSSRS assessed suicidal ideation and behavior in patients'
lifetime and past month. Three questions about religiosity
from a Risk Assessment Measure (RAM) inquired about
belief in God, attendance of religious services, and moral
objections to suicide. Analysis: To examine whether
religiosity was related to outcomes on a standardized suicide
assessment instrument, a secondary analysis was performed
using chi-square tests. ϕ was calculated to determine the
magnitude of possible relationships. Results: A majority of
patients believed in God (86.9%, n = 172) and believed
suicide is immoral (62.4%, n = 123). A minority of patients
regularly attended religious services (38.7%, n = 77). Suicidal
ideation was not less prevalent among those who believed in
God and who had moral objections to suicide. However,
those who regularly attended religious services were less
likely to indicate a past month history of passive (ϕ = - 0.16; p
< 0.05) and active non-specific suicidal ideation (ϕ = - 0.14; p
< 0.05). Patients who believed in God and who had moral
objections to suicide were less likely to have lifetime and past
month history of suicide attempt; ϕs ranged from - 0.17 to 0.23; p < 0.05. They were also less likely to have lifetime
history of suicidal behavior (ϕ = - 0.15, ϕ = - 0.21; p < 0.05).
Past month history of suicidal behavior was less common
among those who believe in God (ϕ = - 0.15; p < 0.05) and
those who regularly attend religious services (ϕ = - 0.17; p <
0.05). This relationship trended for those who had moral
objections to suicide but just missed significance.
Discussion: Adult psychiatric inpatients who attended
religious services exhibited less suicidal ideation. Those who
believed in God, attended religious services, and had moral
objections to suicide exhibited less suicidal behavior. To the
best of our knowledge, this study was unique in employing a
standardized suicide assessment to examine religiosity as a
protective factor for suicidality among adult psychiatric
inpatients. This study adds to the findings on religiosity and
suicidal behavior observed in non-clinical samples and
contributes to the limited literature on religiosity and
suicidal ideation. When assessing for suicidal risk, clinicians
should consider their patients' belief in God, attendance of
religious services, and moral objections to suicide.
P4-42
EVALUATION OF OUTCOMES FROM THE TRANSITIONS
PROGRAMS: A NOVEL OUTPATIENT THERAPY PROGRAM
AFTER HOSPITAL/EMERGENCY DEPARTMENT
DISCHARGE
Lead Author: Nikhil A Patel, M.S.
Co-Author(s): Dr. Mario J. Hitschfeld, MD; Dr. Brian A.
Palmer, MD, MPH
SUMMARY: BACKGROUND: The period following hospital
discharge is a high-risk period for suicide. Data from the
National Association of Psychiatric Health systems has
shown that Medicare beneficiaries who participate in a
partial hospital program have longer time to readmission
(131 days to 59 days). The creation of cost-effective programs
that integrate evidence-based suicide risk reduction
(including emotion regulation skills), sobriety support, goal
setting, and case management has been elusive. At Mayo
Clinic, a team of a psychiatrist, nurse practitioner, psychiatric nurse, social worker, occupational therapist, recreation
therapist, addictions counselor has collaborated to develop
and implement a Transitions Program that accepts daily
admissions from the inpatient units, individualizes groups
and individual treatment for each patient, and closely links
its content and emphasis to the inpatient care model.
OBJECTIVE: Describe a multidisciplinary intensive outpatient program that is closely linked with inpatient care,
describing the program and evaluating its initial short-term
outcomes. DESIGN/METHODS: This is a retrospective chart
review of patients who participated in the Transitions
Program at Mayo Clinic Rochester in 2013. PHQ-9 and
Suicide Status Form (SSF-II) ratings were assessed across
both the inpatient hospitalization (where applicable) and the
Transitions Program using pair-wise comparisons. Descriptive statistics of the patient population demographics were
also obtained. RESULTS: Fifty patients who enrolled in the
program in 2013 with complete follow-up were assessed.
They were 52% women and 48% male with an average age of
37 ± 2 years. Many psychopathologies were evident in this
patient population: major depressive disorder, bipolar
disorder, borderline personality disorder, and schizoaffective
disorder. 82% of patients were referred by hospital inpatient
service; these patients spent 6 ± 1 day in the hospital.
Moreover, the 4% of patients came from the Emergency
Department and 12% from outpatient mental health
providers. The average number of days spent in the Program
was 10 ± 1 day. The 30-day hospital readmission rate was
10% for this cohort, including 8% readmitted to Transitions
Program. PHQ-9 scores were 11 at Transitions admission
and 9 at Transitions Discharge (p=0.08). SSF from admission
to discharge showed statistically significant declines in
patients' feelings of stress and agitation (p=0.04, p = 0.01).
CONCLUSIONS: The Transitions Program provides a bridge
from inpatient hospital emergency evaluations to help
decrease inpatient stay length, increase quality of care, and
help reduce hospitalization. Patients' PHQ 9 scores
decreased by two points after participation in the program,
and patients self-reported distress and agitation was markedly reduced during this high-risk period for suicide. The 30day rate was 10% with 8% participating again in the
Transitions program avoiding hospitalization.
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adaptive behavior and fewer externalizing and internalizing
problems, according to parent and teacher reports.
Moreover, moderated effects indicated that the ethnicity of
the children was an important factor to consider in the
association between ethnic identity and functioning. During
early childhood, ethnic identity may be an important
protecttive factor that can promote the behavioral functioning and mitigate the negative effects of socioeconomic
disadvantage experienced by many Latino children.
P4-44
KETAMINE AUGMENTATION OF ANTIDEPRESSANT
RESPONSE TO ECT IN TREATMENT RESISTANT
DEPRESSION
Lead Author: Ranjit C. Chacko, M.D. Co-Authors: Linda
Barloon, Psych NP
SUMMARY: Introduction: ECT is indicated in patients for
Treatment Resistant Major Depression after trials of several
antidepressants and psychotherapy have failed. Ketamine
has a different mechanism from most antidepressants which
target monoamine uptake inhibitors,instead blocks glutamate binding at the NMDA receptor.A series of studies over
the past 12 years have demonstrated that ketamine produces
rapid reversal of depressive symptoms and suicidal ideation.
Previous case reports and a few studies have shown mixed
results when using ketamine with ECT.Inability to reproduce
a sustained response with ketamine infusions and concerns
about potential physiological and psychological risks have
limited widespread use. The aim of this study was to explore
the potential benefit of ketamine to enhance the effects of
ECT in severely depressed, Treatment resistant patients with
suicidal ideation. Methods: 16 patients with an episode of
severe Treatment resistant Major Depression and suicidal
ideation were included in the study. Age ranged from 39 yrs
to 77 yrs, 12 females and 4 males, Mean PHQ 9 scale score on
entry was 24, representing severe symptoms,all patients
endorsed suicidal ideation. Patients with a history of
substance abuse or psychotic symptoms were excluded.
Patients received a lower than standard dose of propofol
together with ketamine infused at a concentration of 0.5
mgm/kg before receiving ECT.All patients received 8 ECT,
bilateral and RUL electrode placement was utilized as
clinically indicated. Results: 13 patients achieved complete
remission of Depressive symptoms with no suicidal ideation
at the completion of 8 ECT. Mean PHQ 9 score for remitted
patients was 3, representing minimal depression. 4 patients
have required maintenance ECT to maintain remission.
Earlier responses and a positive effect on suicidal ideation
during the course of ECT was seen in all remitted
patients.Ketamine augmentation however did not reduce the
number of ECT required to produce remission.All patients
tolerated the use of ketamine and propofol with no
significant adverse physiologic or psychiatric effects.
Conclusions: Ketamine combined with propofol anesthesia
for ECT may enhance the rapid response of depressive
symptoms and suicidal ideation in patients with Treatment
resistant severe Major Depression.
P4-46
MEDICALLY UNEXPLAINED ILLNESSES AND
SOMATOFORM CONDITIONS IN CHILDREN AND
ADOLESCENTS: A QUALITATIVE EXPLORATION OF
PARENTS’ PERSPECTIVES
Lead Author: Roo T.M. Deinstadt, M.A. Co-Authors: Ayaz K.
Kurji, BScH, MD Candidate 2014, Sarosh Khalid-Khan, MD,
DABPN
SUMMARY: Introduction: Medically unexplained illnesses
and somatoform conditions in children and adolescents can
be physically debilitating and emotionally distressing for
both patients and their families. These presentations are
typically multi-symptomatic and associated with lengthy
medical investigations involving numerous visits to various
health care providers. Little is known about how parents of
affected children and adolescents experience the multifaceted treatment process. Given that successful family
involvement is an integral component of effective treatment,
an understanding of parents' experiences in regards to their
child's condition is paramount. We sought to explore the
lived experiences of parents of children and adolescents with
medically unexplained illnesses or somatoform conditions,
particularly in relation to their interactions with health care
providers. Methods: Purposive sampling was used to select
parents of children and adolescents with medically
unexplained or somatoform conditions who had attended a
psychiatric outpatient clinic in Ontario, Canada. Semistructured interviews were conducted with five participants
(including one parent couple); one of the conditions was
resolved and three were ongoing. The interviews were
transcribed verbatim and an interpretative phenomenological analysis was employed to extract themes from the
data. Results: Main themes included personal distress and
family conflict, both exacerbated by the condition and
related stress. Parents also described positive and negative
changes in relationships, as well as changes in their family's
lifestyle and daily functioning. Parents had various
understandings of the mind-body connection in relation to
their child's condition, and many viewed psychiatry's
involvement as an adjunct. The majority of parents had
limited contact with a primary care provider and all parents
expressed frustration with the lack of continuity of care. As a
result, parents adopted advocacy and leadership roles in
managing their child's care and sought structure in the
search for a diagnosis. Discussion: Findings suggest that the
multiple stressors associated with these conditions interact
to propagate cycles of stress for parents. A holistic approach
to treatment is recommended, involving attunement to the
family system and cycle of stress, psychoeducation for
families and limited referrals and tests for somatoform
conditions. Furthermore, these findings highlight the
importance of communication and collaboration amongst
providers and within parent-provider relationships, and the
central managerial role of primary care providers.
P4-45
LATINO ETHNIC IDENTITY AS A PROTECTIVE FACTOR IN
EARLY CHILDHOOD
Lead Author: Maria A. Serrano-Villar, M.S. Co-Authors:
Esther J. Calzada, Ph.D.
SUMMARY: This study examined child ethnic identity
development and its association with child functioning
among young Latino children enrolled in prekindergarten
and in kindergarten schools. Participants were 4 – 5 year old
children (N=678) and their families and teachers. Children
completed a questionnaire to assess their ethnic identity.
Teachers and mothers reported on children's externalizing,
internalizing and adaptive behavior at school and in the
home. Children's ethnic identity does appear to be emerging
at this young age, in ways that may depend on their gender
and ethnicity and was found to be associated with better
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AMERICAN PSYCHIATRIC ASSOCIATION
P4-48
INCREASED ENERGY/ACTIVITY, NOT MOOD CHANGES, IS
THE CORE FEATURE OF MANIA
Lead Author: Ana-Leticia Santos-Nunes Co-Authors: Elie
Cheniaux, Ph.D., Alberto Filgueiras, Ph.D., Rafael Assis da
Silva, M.D., Luciana Angélica Silva Silveira, M.D., J.
Landeira-Fernandez, Ph.D.
SUMMARY: Background In the Diagnostic and Statistical
Manual of Mental Disorders, 5th edition, the occurrence of
increased energy/activity and elation of mood or irritability
became necessary symptoms for the diagnosis of an episode
of mania or hypomania. Objective To evaluate whether
increases in energy/activity or mood changes represent the
core feature of the manic syndrome.
Methods The
symptomatology of 117 hospitalized patients with bipolar
mania was evaluated using the Schedule for Affective
Disorders and Schizophrenia-Changed version (SADS-C).
Based on six items of the SADS-S related to mania, a
Confirmatory Factor Analysis (CFA) was performed. An Item
Response Theory (IRT) analysis was used to identify how
much each symptom informs about the different levels of
severity of the syndrome. Results According to the CFA, the
item "increased energy" was the symptom with the highest
factorial loadings, which was confirmed by the IRT analysis.
Thus, increased energy was the alteration most correlated
with the total severity of manic symptoms. Additionally, the
analysis of the Item Information Function revealed that
increased energy was correlated with the larger amplitude of
severity levels compared with the other symptoms of mania.
Limitations Only six manic symptoms were considered. The
sample might not be representative because the patients
were evaluated while presenting peak symptom severity.
Conclusions Increased energy/activity is a more important
symptom for a diagnosis of mania than mood changes and
represents the core feature of this syndrome.
P4-47
RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
TRIAL OF ADJUNCTIVE ARMODAFINIL (150 MG) IN
BIPOLAR I DEPRESSION: SAFETY AND SECONDARY
EFFICACY FINDINGS
Lead Author: Mark Frye, M.D. Co-Authors: Caleb Adler, M.D.,
Michael Bauer, M.D., Ph.D., Terence A. Ketter, M.D., Ronghua
Yang, Ph.D.
SUMMARY: Introduction: Bipolar I disorder is a recurrent
and debilitating illness; depressive phases are pervasive and
cause major functional impairment. Only 3 treatments (all of
which have second-generation antipsychotic components
and commonly have substantive adverse effect challenges)
have been approved for bipolar I depression. We report
secondary efficacy endpoints and safety of the low-affinity
dopamine transporter inhibitor armodafinil for bipolar I
depression. Methods: Patients with bipolar I disorder 18-65
years of age with a nonpsychotic major depressive episode
despite stable doses of 1 or 2 of the following: lithium,
valproate, lamotrigine, olanzapine, aripiprazole, risperidone,
quetiapine, or ziprasidone (ziprasidone only in combination
with lithium or valproate), were randomized to adjunctive
once-daily armodafinil 150 mg or placebo. Secondary
efficacy endpoints included rates of 30-item Inventory of
Depressive Symptomatology-Clinician Rated (IDS-C30)
response (≥50% reduction from baseline total score) and
IDS-C30 remission (final IDS-C30 ≤11); as well as changes
from baseline in the 16-item Quick Inventory of Depressive
Symptomatology-Clinician Rated (QIDS-C16), Clinical
Global Impression-Severity of Illness (CGI-S), Global Assessment of Functioning (GAF), Young Mania Rating Scale
(YMRS), Hamilton Anxiety Scale (HAM-A), and Insomnia
Severity Index (ISI). Continuous variables were analyzed
using analysis of variance and categorical efficacy variables
were analyzed using the Cochran-Mantel-Haenszel test.
Results: Of 656 patients screened, 399 were randomized
(n=199 placebo, n=200 armodafinil; mean age 44.5 years ).
Although the primary efficacy endpoint did not reach
statistical significance, adjunctive armodafinil yielded numeric advantages compared with placebo in least-square
mean ± standard error reductions in IDS C30 total (-18.2 ±
1.23 vs -17.1 ± 1.23) and QIDS-C16 (-7.1 ± 0.49 vs -7.0 ± 0.49 )
as well as IDS-C30 responder rate (49% vs 41%) and
statistically significant advantages in changes in CGI-S (-1.3
vs -1.1; P=0.032) and GAF scores (13.5 vs 10.4; P=0.007 ) and
IDS-C30 remitter (22% vs 13%: P=0.011) and CGI-S
responder rates (44% vs 34%; P=0.050). Least square mean
YMRS, HAM-A, and ISI scores improved statistically similarly
in both groups. Adjunctive armodafinil was generally well
tolerated compared with placebo, with statistically similar
rates of manic switch (N=0 [0%] vs 1 [<1%]), anxiety (N=8
[4%] vs N=5 [3%]), insomnia (N=6 [3%] vs N=4 [2%]),
sedation/somnolence (N=2 [1%] vs N=2 [1%]), and
potentially clinically significant (≥7%) weight gain (N=4 [2%]
vs N=9 [5%]). Conclusions: In this study, several (but not all)
secondary endpoints supported advantages for adjunctive
armodafinil in bipolar I depression compared with placebo.
Armodafinil was well tolerated, did not promote manic
switches, and had similar rates of anxiety, insomnia,
sedation/somnolence, and weight gain as that observed with
placebo. Funding: Teva
P4-49
EFFECT OF GENDER REASSIGNMENT HORMONE
THERAPY ON SLEEP ARCHITECTURE
Lead Author: Evalinda Barron, M.D. Co-Authors: Santana
Daniel, Ph.D., Salin J. Rafeal, M.D., Ph.D.
SUMMARY: Background: Transsexualism is defined as the
belief in which an individual identifies with the opposite
gender to their biological sex, desire to live and be accepted
as such, is characterized by a mismatch between gender
identity and biological sex. Both the neurobiology related to
transsexuality, how hormone administration affects the
functioning of the brain structures involved in gender
identity are still unknown. However, it has been found that
transsexuals have neuropsychological testing scores corresponding to the gender with which they identify, the brain
structures such as the hypothalamus and suprachiasmatic
nucleus are comparable. These structures regulate circadian
cycles, which could also have a generic dimorphism in
transsexual subjects. Hypothesis: If hormone therapy transgender reassignment with conjugated estrogens administered for six months, have an effect on the neurophysiology
of these subjects, then we will find changes in sleep
architecture. Primary Objectives: Determine the changes in
sleep architecture after six months of hormone therapy.
Methodology : Six subjects diagnosed with gender identity
disorder according to DSM IV- TR, who met eligibility criteria
were recruited Harry Benjamin: With selected individuals
complete history was made, psychiatric diagnoses were
confirmed with SCID SCID I and II , basal levels of sex and
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2014 INSTITUTE ON PSYCHIATRIC SERVICES
IDS-C30 change from baseline at week 8 was -20.8 ± 0.99 in
the armodafinil group and -19.4 ± 0.99 in the placebo group
(P=0.272). Overall, 89 (45%) patients receiving armodafinil
and 71 (36%) receiving placebo experienced at least one
adverse event (AE); most AEs were mild to moderate in
severity. Only 2 AEs were observed in ≥5% of patients in
either treatment group: headache in 29 (15%) patients vs 15
(8%) and nausea in 12 (6%) vs 7 (4%) in the armodafinil vs
placebo groups, respectively. Serious AEs occurred in 5 (3%)
patients receiving armodafinil and 6 (3%) receiving placebo.
In total, 7 (4%) patients in the armodafinil group vs 10 (5%)
in the placebo group discontinued due to AEs. At endpoint,
there were no clinically significant differences vs baseline in
serum chemistries, lipid profiles, or hematologic and
urinalysis parameters between groups. Sedation/somnolence was seen in 2 (1%) in the armodafinil and 2 (1%) in the
placebo group. Mean weight change at endpoint was -0.5 kg
in the armodafinil group and 0.3 kg in the placebo group. At
least 7% weight gain was seen in 4 (2%) in the armodafinil
group and 9 (5%) in the placebo group. Conclusion: In this
study, adjunctive armodafinil 150 mg was generally well
tolerated and although numerically superior to placebo for
decreasing depressive symptoms, this advantage lacked
statistical significance. Funding: Teva Pharmaceuticals
thyroid hormones was measured and we made a
polysomnography to describe the architecture of basal sleep.
Was administered hormone reassignment therapy with
conjugated estrogens (0.625 mg/d) and retest polysomnography at 24 weeks. Persons not trasexuales control which
was performed polysomnography. Statistical analysis:
Kolmogorov-Smirnov test was used to check normality , then
a general linear model for repeated measures to compare
each of the variables of baseline sleep, the three and six
months, an analysis of Pearson correlation between
hormone levels was performed Finally, an ANOVA test was
performed for the sleep variables between subjects and
control subjects transsexual Results: The proportion of N2
which shows increases; differences between transsexual
women with 6 months of hormone reassignment therapy,
and the other 3 groups was present. Discussion: Whereas the
area involved in gender identity disorder is found in the
hypothalamus, which regulates sleep area and a high
involvement in circadian cycles was important to study its
relevance in transsexual patients has been demonstrated
hormonal influence on the sleep-wake cycle, but our
hypothesis was based on the dimorphism between men and
women in sleep architecture predict the pattern and
changing it in transsexual subjects was mostly theoretical
since this the first study on this. Conclusions. There is a
dependence between sex hormone levels and sleep architecture in transsexual subjects, which is different from nontranssexual men and women
P4-51
RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
TRIAL OF ADJUNCTIVE ARMODAFINIL (150 MG) IN
BIPOLAR I DEPRESSION: SAFETY AND SECONDARY
EFFICACY FINDINGS
Lead Author: Mark Frye, M.D.
Co-Author(s): Caleb Adler, M.D., Michael Bauer, M.D., Ph.D.,
Terence A. Ketter, M.D., Ronghua Yang, Ph.D.
SUMMARY: Introduction: Bipolar I disorder is a recurrent
and debilitating illness; depressive phases are pervasive and
cause major functional impairment. Only 3 treatments (all of
which have second-generation antipsychotic components
and commonly have substantive adverse effect challenges)
have been approved for bipolar I depression. We report
secondary efficacy endpoints and safety of the low-affinity
dopamine transporter inhibitor armodafinil for bipolar I
depression. Methods: Patients with bipolar I disorder 18-65
years of age with a nonpsychotic major depressive episode
despite stable doses of 1 or 2 of the following: lithium,
valproate, lamotrigine, olanzapine, aripiprazole, risperidone,
quetiapine, or ziprasidone (ziprasidone only in combination
with lithium or valproate), were randomized to adjunctive
once-daily armodafinil 150 mg or placebo. Secondary
efficacy endpoints included rates of 30-item Inventory of
Depressive Symptomatology-Clinician Rated (IDS-C30)
response (≥50% reduction from baseline total score) and
IDS-C30 remission (final IDS-C30 ≤11); as well as changes
from baseline in the 16-item Quick Inventory of Depressive
Symptomatology-Clinician Rated (QIDS-C16), Clinical
Global Impression-Severity of Illness (CGI-S), Global
Assessment of Functioning (GAF), Young Mania Rating Scale
(YMRS), Hamilton Anxiety Scale (HAM-A), and Insomnia
Severity Index (ISI). Continuous variables were analyzed
using analysis of variance and categorical efficacy variables
were analyzed using the Cochran-Mantel-Haenszel test.
Results: Of 656 patients screened, 399 were randomized
(n=199 placebo, n=200 armodafinil; mean age 44.5 years ).
Although the primary efficacy endpoint did not reach
statistical significance, adjunctive armodafinil yielded
numeric advantages compared with placebo in least-square
P4-50
RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED
TRIAL OF ADJUNCTIVE ARMODAFINIL (150 MG/D) IN
BIPOLAR I DEPRESSION: SAFETY AND PRIMARY
EFFICACY FINDINGS
Lead Author: Caleb Adler, M.D.
Co-Author(s): Michael Bauer, M.D., Ph.D., Mark A. Frye,
M.D., Terence A. Ketter, M.D., Ronghua Yang, Ph.D.
SUMMARY: Introduction: Bipolar I disorder is recurrent and
debilitating, with a prevalence of ~1%. Although bipolar I
depression occurs 3 times more often than mania, it only has
limited approved treatment options: one as combination
therapy (olanzapine/fluoxetine), another as monotherapy
(quetiapine), and a third as both monotherapy and adjuncttive therapy to lithium or valproate (lurasidone). The
approved bipolar I depression treatments commonly have
more adverse effect challenges than mood stabilizers and
antidepressants, which lack such approval. This study evaluated efficacy and safety of the low-affinity dopamine
transporter inhibitor armodafinil as an adjunctive therapy
for bipolar I depression. Methods: Bipolar I disorder patients
18-65 years of age with a major depressive episode (without
psychosis) despite stable doses of 1 or 2 of the following:
lithium, valproate, lamotrigine, olanzapine, aripiprazole,
risperidone, quetiapine, or ziprasidone (ziprasidone only in
combination with lithium or valproate), were randomized to
adjunctive once-daily armodafinil 150 mg or placebo. The
primary efficacy assessment was change from baseline to
week 8 in the 30-item Inventory of Depressive Symptomatology-Clinician-Rated (IDS-C30) total score analyzed by
mixed-model repeated measures. Safety and tolerability
were monitored throughout the study. Results: Of 656
patients screened, 399 were randomized (n=199 placebo,
n=200 armodafinil; mean age 44.5 years). Baseline mean
IDS-C30 scores were 42.4 in the armodafinil group and 43.5
in the placebo group. Least squares mean ± standard error
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AMERICAN PSYCHIATRIC ASSOCIATION
workers seeking treatment for physical symptoms related to
their WTC exposure. For patients recruited only on the basis
of WTC-related medical symptoms during May 2005 and
February 2009, most patients reported mental health
symptoms (60.8%), and the prevalence of probable PTSD
was 42.2%, depression 55.5%, and general anxiety 28.4%. The
presence of respiratory symptoms emerged as the strongest
risk factor for probable PTSD. Findings suggested the
importance of screening and continued assessment of
persistent probable PTSD in populations seeking medical
treatment after a major terrorism-related disaster, corroborated studies of First Responders as well. Treatment of
patients with co-morbid anxiety-spectrum and depressive
symptoms as well as respiratory problems presents unique
challenges and opportunities in an integrated care setting,
particularly as rates of PTSD, depression, and anxiety remain
persistently elevated even 12 years after the attack.
mean ± standard error reductions in IDS C30 total (-18.2 ±
1.23 vs -17.1 ± 1.23) and QIDS-C16 (-7.1 ± 0.49 vs -7.0 ± 0.49 )
as well as IDS-C30 responder rate (49% vs 41%) and
statistically significant advantages in changes in CGI-S (-1.3
vs -1.1; P=0.032) and GAF scores (13.5 vs 10.4; P=0.007 ) and
IDS-C30 remitter (22% vs 13%: P=0.011 ) and CGI-S
responder rates (44% vs 34%; P=0.050 ). Least square mean
YMRS, HAM-A, and ISI scores improved statistically similarly
in both groups. Adjunctive armodafinil was generally well
tolerated compared with placebo, with statistically similar
rates of manic switch (N=0 [0%] vs 1 [<1%]), anxiety (N=8
[4%] vs N=5 [3%]), insomnia (N=6 [3%] vs N=4 [2%]),
sedation/somnolence (N=2 [1%] vs N=2 [1%]), and
potentially clinically significant (≥7%) weight gain (N=4 [2%]
vs N=9 [5%]). Conclusions: In this study, several (but not all)
secondary endpoints supported advantages for adjunctive
armodafinil in bipolar I depression compared with placebo.
Armodafinil was well tolerated, did not promote manic
switches, and had similar rates of anxiety, insomnia,
sedation/somnolence, and weight gain as that observed with
placebo. Funding: Teva
P4-54
LONG-TERM AFTERCARE COMPLIANCE, RELAPSE AND
MORTALITY AFTER RESIDENTIAL SUBSTANCE USE
TREATMENT
Lead Author: Kathleen Decker, M.D. Co-Authors: Stephanie
Peglow, D.O., Carl Samples, B.A.
SUMMARY: Background: Treatment of substance use
disorder is a high priority. Residential treatment has been
associated with improved mortality and morbidity in those
who complete treatment. The current study sought to
examine a number of long-term outcome measures after
residential treatment. Method: Veterans (n=206) admitted to
residential substance use treatment were followed for five
years after discharge to assess aftercare compliance,
mortality and relapse. Data on VA aftercare attendance,
relapse and mortality were obtained using VA's national
electronic medical record. Results were analyzed with SPSS,
version 18. Results: The sample was 91% male, 72% AfricanAmerican, 25% Caucasian and 3% other. The mean age was
50. Aftercare attendance was lower in those irregularly
discharged (p<0.01). Fifty-three percent of all patients
relapsed within five years. Females and patients with
comorbid disorders relapsed earlier using Cox survival
analysis (HR 2.2, p=0.03; HR, 1.3, p=0.02). Homelessness
prior to admission, prior intensive outpatient treatment and
comorbid disorders were associated with increased risk of
relapse and prior residential treatment was associated with
reduced risk of relapse using binary logistic regression.
Patients who were regularly discharged had a lower rate of
readmission to substance use rehabilitation (Χ2=4.51,
p=0.04). Patients transferred to transitional residence after
residential treatment had a lower death rate (5%) than
patients irregularly discharged (23%) (Χ2=6.08, p=0.05). The
only variable that was significantly associated with a reduced
risk of death in logistic regression analysis was a longer
length of time before relapse (p=0.04). Conclusions:
Comorbid psychiatric conditions, homelessness and prior
intensive outpatient treatment were associated with a higher
relapse rate and prior residential treatment was associated
with a lower relapse rate. Aftercare attendance of those who
fail to complete residential treatment was lower. Limitations
include that this population has severe substance use
disorder and that attendance at Alcoholics Anonymous
aftercare was not followed.
P4-52
{+/-}3,4-METHYLENEDIOXYMETHAMPHETAMINE IN
COMBAT RELATED PTSD: A REVIEW AND COMPARISON
WITH AND WITHOUT PSYCHOTHERAPY
Lead Author: Cole Marta, M.D.
Co-Author(s): Benjamin Schechet, BA.; Ralph J. Koek, M.D.
SUMMARY:
Background: Until its criminalization in 1985, +/-3,4methylenedioxymethamphetamine (MDMA) was used as
pharmacotherapy by psychiatrists. After more than 25 years,
Mithoefer et al performed the first clinical trial evaluating
MDMA as adjunct treatment was reported in the literature.
This clinical trial demonstrated significant improvement in
Clinician-Administered PTSD Scale (CAPS) when MDMA was
administered in conjunction with psychotherapy in limited
sessions as part of a longer course of psychotherapy. These
treatments were provided without evidence of harm in
patients with refractory PTSD. Other studies utilizing MDMA
for PTSD with and without psychotherapy, a follow up of
Mithoefer's study, and preliminary results of a second
Mithoefer study were reviewed. We compare results
regarding safety and efficacy, as well as techniques utilizing
different psychotherapies, to include no psychotherapy.
Results show that MDMA utilized outside of a psychotherapy
session did not show significant improvement in CAPS
scores. Significant improvement was demonstrated
repeatedly, and with evidence of lasting effect, by the
Mithoefer group which was not repeated when utilizing
prolonged exposure therapy (PE).
P4-53
INTEGRATED TREATMENT FOR COMMUNITY MEMBERS
AFFECTED BY THE 9/11 WORLD TRADE CENTER
DISASTER
Lead Author: Nomi C. Levy-Carrick, M.D.
SUMMARY: The September 11, 2001 (9/11) collapse of the
World Trade Center (WTC) towers in New York City (NYC)
caused substantial physical and mental health sequelae in
the local population. This study examines the prevalence
and risk factors of persistent Post Traumatic Stress Disorder
(PTSD) symptoms among a cohort of 1,825 patients
comprised of local residents, local workers, and cleanup
128

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