APA 2012

BY MARK MORAN

Seven cutting edge researchers presented original research relevant to psychiatry and psychiatric patients at a special presentation chaired by Jeffrey Borenstein, M.D., editor of Psychiatric News. Ronit Kedem Dedesma, M.D., consultation-liaison psychiatrist at Cambridge Health Alliance and instructor at Harvard Medical School, discussed her research on, “Using an Electronic Medical Record to Improve Monitoring for Patients on Antipsychotic Medicines.” Dr. Dedesma said patients with serious mental illness (SMI) are less likely to receive adequate management of diabetes, high cholesterol, and heart disease, and noted that antipsychotic medications used to treat SMI increase the risk of diabetes and other health problems.

She described an effort at Cambridge Health Alliance to use electronic medical records (EMR) to provide education and reminders about the need to monitor for metabolic status in patients with SMI for clinicians in family medicine, internal medicine, and psychiatry. However, between 2010 and 2011, there was no significant difference in clinician behavior with regard to monitoring metabolic status, suggesting the need to further refine efforts. “Rates of monitoring patients on antipsychotics for metabolic parameters is suboptimal and our interventions have not yet been effective,” she said. “We are working to implement more EMR tools and systems changes to increase awareness and follow through.”

Peter J. Neumann, Sc.D., Director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center and Professor of Medicine at Tufts University School of Medicine, talked about his research looking at “The Hidden Costs of Attention Deficit/Hyperactivity Disorder.” He found that while the magnitude of estimates varies widely – with incremental costs of ADHD ranging between $101 – $163 billion – overall the analysis indicates that ADHD is associated with a substantial individual and societal economic impact. Dr. Neumann said the major cost drivers are work-related costs: income losses due to lower wages and unemployment and education-related costs. “Results indicate need for policies that incentivize third-party payers to consider all cost sectors when evaluating cost-effectiveness of coverage and ADHD treatments,” he said.

Umesh Vyas, M.D., Chair of the Department of Psychiatry and Medical Director of the Behavioral Health Unit and Medical Director of Sleep Disorders Center, Mayo Clinic Health System, described his research on “Treating Sleep Disorders has Positive Outcomes in Psychiatric Illness.”

He performed a review of electronic medical records for diagnosis of sleep disorders at Clement J. Zablocki VA Medical Center in Milwaukee from October 2007 to December 2007. Patients with confirmed diagnosis and treatment for sleep disorders were included and outcomes in patients with comorbid psychiatric disorders were recorded at 6, 12 and 24 months after initiation of sleep disorder treatment.

He found that treatment of comorbid sleep disorders was associated with significant improvement in psychiatric disorders and that psychiatric disorders did not affect compliance with sleep disorders treatment. Dr. Vyas noted that there is a strong need for prospective studies with more subjects.

Other presenters included Abid Malik, M.D., Medical Director at the Sleep Disorder Center, South Seminole Hospital of Orlando Health; David Tran, a medical student at David Geffen School of Medicine at UCLA; Janet Williams, Ph.D., Vice President of Clinical Development, MedAvante, Inc.; and Dinesh Mittal, M.D., Associate Professor, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Arkansas for Medical Sciences.

BY MARK MORAN

Mindfulness — the practice of training the mind to be fully attentive to the present moment, without judgment — has in the last two decades entered the lexicon of medicine, psychiatry, and social work with the potential to transform the way we think of mind, body and healing.

That’s what Jon Kabat-Zinn, Ph.D., Professor of Medicine Emeritus at the University of Massachusetts Medical School, told psychiatrists Saturday during a presidential symposium on “Mindfulness-Based Practices in the Treatment of Stress and Psychiatric Illness at APA’s Annual Meeting in Philadelphia.

“We are at a momentous crossroads in all of the various medical disciplines that have to do with the mind and brain and how we understand the brain in relationship to what we call the mind and what we call the body, and what we call community and how we relate to each other,” Dr. Kabat-Zinn said. “There are remarkable studies going on [with subjects] across the age span in which learning how to be more present and more accepting and clearer about our own experience and not being caught in the usual traps can be profoundly liberating and preventative.”

Dr. Kabat-Zinn, a renowned author and founding director of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, has merged his early interest in and practice of Zen Bhuddist meditation with Western medicine to help people cope with stress, anxiety, pain, and illness. During Saturday’s symposium, Dr. Kabat-Zinn spoke on “Mindfulness-Based Stress Reduction (MBSR): What It Is and Its Clinical Applications for Stress, Pain, and Chronic Illness.”

Other speakers included Peter Beiling, Ph.D., director of mental health and addictions at St. Joseph’s Healthcare in Ontario, John W. Denninger, M.D., Ph.D., director of research at the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, and Sara Lazar, Ph.D., neuroimaging researcher at Harvard Medical School.

Dr. Kabat-Zinn spoke at length about what mindfulness is — and what it is not — and he cautioned that what it is not is merely another form of cognitive therapy. Rather, it is a “way of being,” a practice of being fully awake to the present moment that is ultimately very hard to learn and quite at odds with the distracted multi-tasking culture of western society. “…It’s easier said than done. The first thing you notice when you cultivate mindfulness is how mindless we are,” he said. “This turns out to be the hardest thing for us to do — to be present and to string moments of presence together.”

But he said that the understanding and practice of mindfulness has begun to transform Western society and healing practices in a way that could not have been imagined 50 years ago. “Carl Jung said the methods and philosophical doctrines that have developed in this regard simply put all Western efforts to shame,” Dr. Kabat-Zinn said. “So he was very impressed by [Eastern concepts of mindfulness], but he also said that there was no way a Westerner could ever understand this. He said there was a cultural divide between what we quaintly called the East and West…But if he came back now, he would be completely mind-blown. Today you can say there is more interest in mindfulness in the West than there is in the East.”

He added, “I think it is diagnostic that APA is having this presidential symposium and what would be really fun is to come back in 10 years and see how it has all unfolded.”

Correcting educational and health disparities and addressing undiagnosed mental health needs in the African American community will be vital in overcoming the increasing incarceration rates of black males and juveniles in the United States. This was the conclusion of a panel of experts who discussed untreated mental disorders in this population yesterday morning during a workshop titled “Incarceration of Black Males: The Effects of Untreated Bipolar, ADHD, and Substance Abuse Disorders.”

In addition, cultural roadblocks, media depictions of the “super thug,” and the booming prison industry all contribute to the acceptance of over-incarceration of black males in America, the panel agreed.

“At any given time, one-third of black men are in the legal system, including incarceration, probation, or parole,” said Otis Anderson, M.D., a psychiatric specialist with Tri-Lakes Behavioral Health, Batesville, Miss. “There’s a huge industry in locking people up.”

Napoleon B. Higgins, M.D., CEO and President of Baypoint Behavioral Health Services in Houston, presented chilling statistics of the overwhelming growth of the penal system in Texas. Between 1980 and 2004, there was a 566 percent increase in the prison population and a 1,600 percent increase in corrections spending, he said.

Drug use is often cited as cause for the overabundance of black males in the prison system, Dr. Higgins said. However, African Americans make up only 13 percent of daily drug users in the U.S., he said, even though they represent the vast majority of the prison population.

Arrest statistics also paint a troubling picture. For example, 55 percent of crack users in the United States are white but 74 percent of people incarcerated for crack use are black, Dr. Higgins said.

“Drugs are an excuse to put black people in jail,” Dr. Higgins said. “Disparities exist in drug-related incarcerations. Police are hunting out black males because they are the face of violent crime in the media.”

Indeed, all of the panelists cited media depictions of the black male as a violent crime instigator as one of the leading factors contributing to the growing imprisonment of African Americans. “In media and rap music, essentially you can be aggressive, violent, and hypersexual with no consequences to behavior,” Dr. Higgins said. “The promotion of that manic-type ‘super thug’ drives a lot of kids to believe that people actually live like that.”

When black males are incarcerated, there is a lack of diligence in diagnosing and treating mental illness and disorders, said Rahn K. Bailey, M.D., Chairman of Psychiatry and Behavioral Sciences at Meharry Medical College, Nashville. But in many cases, mental disorders such as ADHD that could have been diagnosed and treated in childhood are left undiscovered until a person has landed in the penal system.

“The reality is African American males are people, too,” Dr. Bailey said. “They have clinical psychiatric illnesses such as ADD, ADHD, bipolar disorder, and schizophrenia and they need to be treated.”

Dr. Bailey advocates for early diagnosis and treatment, but says cultural issues within the black community provide a roadblock for early intervention and treatment of many mental disorders. For example, there’s a huge social stigma attached to ADHD diagnosis and treatment.

“Parents need to be educated that this is not a bad thing or an albatross around their child’s neck,” said Dr. Bailey, who also cited the need for psychiatric organizations working with minority patients to make sure the information distributed in the community is appropriate and culturally sensitive.

When a diagnosis is made and treatment is offered, other challenges include cultural, environmental, ethnic, and genetic factors that play into the toxicity, metabolism, and side effects of medication.

Johnny Williamson, M.D., Chief Medical Officer Clinical Director of the Pediatric Psychiatric Unit at Hartgrove Hospital, Chicago, highlighted some of the drug-related interactions associated with genetic and cultural factors. For example, African American children are more likely to experience high blood pressure when taking a stimulant for ADHD, he said.

Dr. Williamson recommended rational psychopharmacotherapy, treating each person individually, discussing the factors that will impact treatment, and establishing an effective treatment alliance. “I’ve only seen a positive benefit when I’ve been able to be knowledgeable about, discuss, and include in my treatment some aspect of talking about what a person’s culture, desires, preferences, and understandings are,” he said.

Each year the membership of the APA elects members to the Board of Trustees to undertake the responsibility of governing the Association. While the power to make policy is vested in the Board, their primary function is to formulate and implement the policies of the Association. Please take a moment to exercise one of your member benefits and participate in the nomination and election of the Association’s leadership.Nominations and letters of recommendation can be submitted to election@psych.org.

The slate of candidates is announced on the APA website, www.psychiatry.org, November 1. Eligible voting members can expect to vote with an e-mailed electronic ballot or mailed paper ballot during the month of January. Mark your calendars!

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