APA 2012

As the population ages and psychiatric patients develop more comorbid conditions, the field of psychiatry will come in closer contact with other medical specialties, according to Kenneth R. Silk, M.D., Chair of the 2012 APA Scientific Program Committee. This year’s meeting is about preparing for and embracing that change, while also celebrating how vital and wide-ranging the psychiatric specialty has become.

“I hope the meeting will remind more people that psychiatry is a part of medicine,” said Dr. Silk, who worked closely with Committee Co-chair Michael F. Myers, M.D., and the rest of the committee and the APA staff to plan this year’s scientific sessions. The meeting’s theme — integrated care — reinforces Dr. Silk’s strongly held belief that the psychiatry profession must broaden its outlook.

“We are part of the medical community, and first and foremost we are physicians,” Dr. Silk said. “Even if we see ourselves as psychiatric physicians, we are still a part of that larger medical community. I think that will be evident at the meeting, especially if one thinks of the scientific basis of psychiatric practice.”

After two full days of sessions, the meeting unofficially kicks off at Sunday’s Opening Session, which has been reworked this year into a discussion format featuring Aaron Beck, M.D., and Glen Gabbard, M.D. The two experts will discuss the session’s central question, “Cognitive Therapy and Psychodynamic Therapy: More Alike Than Different?” The two-hour session, which will be moderated by APA President John M. Oldham, M.D., will begin at 4:30 p.m. in the Terrace Ballroom, Fourth Floor, Pennsylvania Convention Center.

Dr. Silk said the concept for the discussion format came from Dr. Oldham, who attended a similar session at a medical meeting in Argentina. The new format presented several logistical challenges, and Dr. Silk credited the APA staff for solving each one.

“The staff knows what needs to be done and they are more than willing to do what they must to make it happen,” Dr. Silk said. “And they are not just willing, they are excited that this session is occurring. That’s been my experience over and over again. It really has made the planning process fun.”

Dr. Silk, who is Professor in the Department of Psychiatry at the University of Michigan and Director of the Personality Disorders Program in the University of Michigan Health System, has served on the Scientific Program Committee for two three-year terms. This is his first year as chairperson.

The process of selecting the educational lectures, symposia and workshops for the program is a time-consuming and lengthy one, he said. The diverse topics covered this year include neuroscience, schizophrenia, law in psychiatry, ethics, military psychiatry, personality disorders and issues in diagnosis.

The APA president chooses the meeting’s theme every year, and some sessions are solicited to cover the theme and other trending topics. Additional tracks are chosen based on interest at previous meetings, such as this year’s military track, which was well received last year in Hawaii. Other tracks emerge from submitted abstracts. Each abstract is scored by at least two reviewers.

The committee then puts together tracks based on scores of the individual abstracts. The committee also collaborated with the Scattergood Program for the Applied Ethics of Behavioral Healthcare and The Thomas Scattergood Behavioral Health Foundation to develop an ethics track. The track features two symposia, 12 workshops and one seminar over the five days of the meeting.

“This is the first time we’ve had an ethics track and Scattergood seems interested in doing that each year at the APA,” Dr. Silk said. “They have been great in their willingness and enthusiasm to be a part of the meeting.”

Another important APA partner is the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which is once again sponsoring a track at the Annual Meeting, “Integrating Treatment for Alcohol Problems and Co-occurring Conditions in Psychiatric Care: Challenges and Successes.” The track includes five symposia, a forum, five workshops and two lectures.

“I know from past meetings that the quality of what the NIAAA presents is superb. Those sessions have always been well attended,” said Dr. Silk, who has attended the APA Annual Meeting for more than 30 years. “Substance use and misuse and now prescription drug — particularly pain drug misuse — is a major problem in our society and this is an opportunity for attendees to get current and appreciate the extent of that problem.”

Another topic area that Dr. Silk is excited about this year will feature updates on DSM-5, which is due to be published next year. Ten symposia, a forum and a lecture are scheduled to cover various facets of DSM-5.

“A lot of people rely on the press and what is said in the national media about DSM-5,” Dr. Silk said. “This will give people a chance to hear what is actually happening. There may be some early — or not so early — results from field trials that people will be able to hear, and I think they’ll appreciate all the work and deliberations that have gone into the DSM-5.”

Organizing five days of sessions on such a wide array of topics can be challenging for the committee, Dr. Silk said. It can be even more challenging for attendees trying to decide which sessions to attend. This is also a problem for the Chair of the Scientific Program Committee, Dr. Silk, who is a personality disorder specialist.

“I am always caught between going to meetings on personality disorders to make myself even more current and to see my friends, who often present in those sessions. Or do I go to sessions that I know absolutely nothing about?” Dr. Silk said. “I may not get another chance for a year to hear people present on those topics. I can go to journals and read about them, but to see and listen to the major players here is a unique opportunity. I feel like that kind of conflict is terrific.”

Bankole A. Johnson, D.Sc., M.D., Ph.D., has a clear message for APA members: Alcohol dependence is a well-understood medical disease that should be treated using data-driven methods. Prof. Johnson will discuss the latest science on alcohol dependence during his lecture “Musings on Decades of Progress in Alcoholism Treatment Research,” which is part of the National Institute on Alcohol Abuse and Alcoholism lecture series. He will speak from 3:30 p.m. – 5 p.m. Saturday in Room 115A-C, Level 1, Pennsylvania Convention Center.

“I’m going to talk about modern treatments and how they can be used and applied,” Prof. Johnson said. “I am going to talk about what constitutes a successful outcome to treatment and whether abstinence is really necessary or whether a reduction in a person’s heavy drinking pattern is sufficient progress.”

Prof. Johnson will review several new drugs used to treat alcohol dependence and will also discuss how the molecular genetics of alcohol dependence can be used to develop new treatment approaches. He will also address various myths about alcohol dependence and how they have defined treatment. He will also share his thoughts on what constitutes a successful response to treatment and the importance of the placebo response to understanding the overall treatment process.

“I want people to focus on what the data say — what the science actually says in terms of treatment — and not spend their time worrying about the myths or their preconceptions,” Prof. Johnson said. “If practitioners were actually able to treat patients in an empirical manner based on a data-driven, scientific method, they would be likely to have positive outcomes for their patients.”

Prof. Johnson, who is Alumni Professor and Chair of the Department of Psychiatry and Neurobehavioral Sciences and Professor in the Departments of Neuroscience and Medicine at the University of Virginia, began his studies into alcohol dependence as a doctoral student at Oxford University in the United Kingdom. His thesis professor suggested that he find a drug that would cure alcohol dependence and submit it as his thesis topic. This led Prof. Johnson, who had no background or personal exposure to alcohol dependence, to a career in addiction recovery science. “Because I didn’t come from a typical addiction treatment background, I had a very open mind to let the evidence lead me where it took me. My approach is very much based on a solid background in doing a doctorate,” Prof. Johnson said. “Of course, I wasn’t able to cure alcohol dependence, but I was able to develop some ideas and theories.” Prof. Johnson’s doctoral work on ion channels led to further research into the neuropsychopharmacology of addiction. His expertise and unique perspective will provide attendees at Saturday’s session with a fresh, data-driven approach to the treatment of alcohol dependence.

Statistics show that only 10 percent of those who need treatment for alcohol dependence receive that treatment. “Ninety percent do not receive treatment. Those are shocking numbers and we need to change that statistic,” Prof. Johnson said.

Another shocking statistic is the high cost of not treating alcohol dependence. A new Centers for Disease Control and Prevention (CDC) study indicates that the annual cost of alcohol abuse, including binge drinking, to the U.S. economy is $223.5 billion. Binge drinking is of particular concern to the CDC because binge drinkers often don’t recognize their alcohol dependence.

“A lot of these individuals do not have sufficient education about alcohol and its harmful effects during their binges, so they are not getting treatment for their binge drinking,” Prof. Johnson said.

Practicing physicians and psychiatrists must become more aware of the modern treatments for alcohol dependence, he added. “Many believe that the treatments are mostly futile,” he said. “Most erroneously believe that abstinence is the only endpoint, and therefore they don’t realize when their patient is actually succeeding in treatment.”

At the age of 168, APA returns to the city of its birth for this year’s annual meeting

BY JOAN AREHART-TREICHEL

Any history of American psychiatry would have to start with a large chapter on Philadelphia. Pennsylvania Hospital, founded in 1751 in Philadelphia by physician Thomas Bond, along with his good friend Benjamin Franklin, was not only America’s first hospital, but the first American hospital to care for people with mental illness. So pleased was Franklin with the creation of the hospital that he later stated, “I do not remember any of my political maneuvers, the success of which gave me at the time more pleasure…”

Benjamin Rush was a Philadelphia physician who worked in the Pennsylvania Hospital from 1783 to 1813. He was among the first Americans to recognize that psychiatric illnesses could be diagnosed, classified and treated, and he was instrumental in upgrading patients’ living conditions and doing away with their handcuff restraints, which were common at the time.

He believed that alcoholism was a medical disease and, unlike most of his contemporaries, not a sin. He proposed that alcoholics should be weaned from their addiction using less potent substances. He encouraged patients to sew, garden, listen to music, and exercise. His practices and beliefs earned him the description “father of American psychiatry.”

And because many of the patients at Pennsylvania Hospital were mentally ill, another facility, the Institute of Pennsylvania Hospital, was built to minister specifically to their needs. In the winter of 1841, nearly a hundred mentally ill patients were transferred in carriages from Pennsylvania Hospital through the bustling city streets to this new rural facility. It stood west of Philadelphia, amid 113 acres of woods and meadows.

This new facility offered a treatment philosophy and level of comfort that would set a standard for its day. For example, the facility comprised an impressive main building and two detached ones surrounded by lush lawns and gardens. Its sunny, airy halls and spacious walks set a standard for hospitals elsewhere.

Moreover, the Institute of Pennsylvania Hospital’s first superintendent was physician Thomas Kirkbride. In 1844, Kirkbride and 13 other physicians came together at the institute and a nearby hotel to found an organization – the Association of Medical Superintendents of American Institutions for the Insane – that was later renamed the American Medico-Psychological Association and finally American Psychiatric Association. This organization was also the first national medical society in America.

Rush is buried in the Christ Church Burial Ground in Philadelphia, not far from Benjamin Franklin’s final resting place.

Visitors are invited to tour Pennsylvania Hospital, located at Eighth and Spruce streets. More information is available by phone at (215) 829-3370 or online at www.pennmedicine.org/pahosp/vi_files/historictours.html. Christ Church Burial Ground is located on Arch Street. It is open to the public daily until 4 p.m., weather permitting. Information is posted at www.christchurchphila.org/burial.

One of the major barriers to integrated care is finding ways to finance it. A Sunday morning workshop titled “Best Financial Practices for Fiscally Solvent Delivery of Integrated Care” will offer solutions.

The four-hour workshop will begin at 8 a.m. in Room 112B, Level 1, Pennsylvania Convention Center.

“The reason that integrated care is the theme for this year’s meeting is to help psychiatrists working in isolated settings look at new practice opportunities,” said Roger Kathol, M.D., President of Cartesian Solutions, Inc.™ and Adjunct Professor of Internal Medicine and Psychiatry at the University of Minnesota. “Providing psychiatric care in primary care settings is one such opportunity, but there are challenges in doing so due to separate financing for mental health and medical services.”

Dr. Kathol said psychiatrists need strategies for creating financially sustainable programs. During Sunday’s workshop, he will discuss integrating claims adjudication as a strategy for reversing the negative effects of comorbid medical and mental health disorders. Three other speakers will join him during the session. “We’ll all be talking about how psychiatrists can integrate psychiatric and medical care and find the best ways to finance it,” Dr. Kathol said.

One of the speakers will take attendees through system-level and care delivery-level mental health reimbursement from a business/administration perspective. Another will provide a psychiatrist’s care-delivery perspective and a third will provide an actuary’s populationbased perspective.

The speakers will address the impact of financing a sustainable interdisciplinary care model in both the psychiatric and medical settings, and how to best finance an integrated psychiatric and medical care environment. They will also divide attendees into groups and ask them to identify their own reimbursement barriers and then come up with strategies to overcome those barriers.

“This is really exploring where those barriers are and coming up with solutions so that psychiatrists who are interested in expanding their practice have a game plan,” Dr. Kathol said. “It will help participants create a financial structure that allows expansion to succeed.”

The workshop will only cursorily address coding, billing and collections. The majority of the session will explore reimbursement approaches that recognize a psychiatrist’s contributions to integrated patient health. The workshop should be of special interest to early and mid-career psychiatrists interested in capitalizing on healthcare reform.

“The workshop is for those psychiatrists interested in working in a medical setting, which is the direction healthcare is going,” Dr. Kathol said. “Core components of health reform are patient medical homes and accountable care organizations. Psychiatrists, recognizing that mental health comorbidity in patients with chronic medical illnesses lead to poor clinical and cost outcomes, have a major contribution to make but need to have a strategy to get there.”

The workshop will feature a presentation by Stephen P. Melek, a principal and consulting actuary at Milliman, an independent actuarial and consulting firm. Mr. Melek has worked with several managed medical and behavioral healthcare organizations on parity issues and cost analysis. He has also consulted on mental health utilization and costs in primary care settings, psychotropic drug treatment patterns, and strategic behavioral healthcare system redesign. He also has experience with plan design, pricing, capitation and risk analysis, provider reimbursement analysis and strategies, healthcare revenue distribution, and utilization management analysis.

Also speaking are Susan Sargent, M.B.A., President of Sargent Healthcare Management Advisors, LLC, and Chris White, M.D., J.D., Assistant Professor of Psychiatry and Family Medicine at the University of Cincinnati.

The National Institute on Drug Abuse (NIDA) will once again present a series of symposia at the Annual Meeting, as well as a unique educational theater presentation by the Addiction Performance Project. The sessions are designed to provide psychiatrists with information and resources to help them identify and intervene with patients at heightened risk of substance abuse, according to Nora Volkow, M.D., NIDA Director.

“Patients with psychiatric diseases are at much greater risk for substance abuse disorders,” Dr. Volkow said. “In these especially vulnerable patients, addressing substance abuse is crucial for getting good outcomes. In addition, the use of substances themselves has a role in triggering mental illness.”

The Addiction Performance Project will perform a dramatic reading from Eugene O’Neill’s play Long Day’s Journey Into Night. The performance will feature professional actors, including Academy Award-winning actress Dianne Wiest, and will be followed by an expert panel reaction and audience discussion. This unique event will begin at 11 a.m. Tuesday in Terrace Ballroom IV at the Pennsylvania Convention Center.

The play is semi-autobiographical, offering a wrenching and realistic portrayal of a family torn apart by drug and alcohol abuse. O’Neill’s mother was addicted to morphine and he abused alcohol. “It is very timely because right now one of the most problematic issues in substance abuse disorders is the abuse of opiate medications,” Dr. Volkow said. “This is not something that physicians pay much attention to because there is the sense that if you prescribe an opiate medication for pain, patients don’t become addicted. But this is not always the case.”

Opiates can become addictive, as the play clearly and eloquently presents through the portrayal of the mother, Dr. Volkow said. “By portraying a patient addicted to a medication prescribed by a physician, the play brings to light the often tragic consequences of addiction and why physicians need to be aware of the potential for it in their patients,” she said.

Dr. Volkow said Tuesday’s performance is a unique way to break down the stigma around addiction and will serve as a springboard for discussion about the challenges and opportunities in caring for drug-addicted patients. More details about the Addiction Performance Project can be found at www.drugabuse.gov/nidamed/ about-addiction-performance-project.

The four NIDA symposia at the meeting highlight areas of NIDA-funded research that intersect with psychiatric treatment of disorders related to substance use and addiction. They are:

• “Social Stress and Drug Addiction in Preclinical and Clinical Studies,” which will be held from 2 p.m. – 5 p.m. Saturday in Room 103A, Level 1, Pennsylvania Convention Center
• “Neurobehavioral and Pharmacological Approaches to Target Cognitive Remediation in Drug Addiction,” which will be held from 1 p.m. – 4 p.m. Sunday in Room 120A, Level 1, Pennsylvania Convention Center
• Dysconnectivity of the Brain in Addiction and Pain,” which will be held from 9 a.m. – noon Monday in Room 126A, Level 1, Pennsylvania Convention Center
• “Assessment of Substance Use Disorder Patient Outcomes Based on Longitudinal Registry/EMR Data,” which will be held from 9 a.m. – noon Tuesday in Room 124, Level 1, Pennsylvania Convention Center

Dr. Volkow said Monday’s symposium will explore the use of imaging to develop biomarkers for mental illness. “Over the past three or four years, new developments in imaging — specifically in the use of MRI technology — have opened up the possibility of developing tools that may be helpful in characterizing patients on a clinical basis and not just for research purposes,” she said.

Substance dependence changes structural and functional connectivity, which addiction researchers are mapping through use of neuroimaging technologies like fMRI. Monday’s symposium will examine the brain circuitry involved in substance dependence and pain, and how new imaging technologies can add to our understanding of these processes.

“It’s going to be very exciting because we have the tools to start to create standards of what normal populations look like and compare that against the status of a particular patient,” Dr. Volkow said. “Two or three years from now, I think we will be at that stage to develop the biomarkers for the normal functioning of the brain across developmental stages and [examine] how that is disrupted by mental illness.”