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NAPPP
NATIONAL ALLIANCE of PROFESSIONAL
PSYCHOLOGICAL PROVIDERS
April 2015
Volume 10 No. 4
The Clinical Practitioner
Thank you
Members and Guests
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2015 Conference
Professional Psychology: Business Practice
& Treatment Perspectives
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© 2014 National Association of Professional Psychological Providers TCP Online ISSN 2373-4787
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1
The Clinical Practitioner
April 2015 Vol. 10 No. 4
Contents:
By John Caccavale, Ph.D.
The Dunning-Kruger Effect
by John Caccavale
Pg. 2
Lessons Learned and a Look to the Future
by Jerold Pollak
Pg. 6
A Bill To Help Foster Care Children
by Kelly Patricia O’Mear
NICE Guidance on depression
Hearing voices more complex
Recent dementia research
FDA News
Science Notes- Drugs
Science Notes- Alternative Approaches
Behavioral News
By Levon Margolin
April CE questions
By Gary Traub
Free CE Course List
How to Write a Brilliant Submission
(Submission Guidelines).
The Dunning-Kruger Effect in
Professional Psychology
Pg. 13
Pg. 14
Pg. 17
Pg. 19
Pg. 24
Pg. 25
Pg. 29
Pg. 36
Pg. 42
Pg. 43
Pg. 45
Editor-In-Chief
David Reinhardt Ph.D.
Editors
Sharna Wood, Ph.D.
Gary Traub, Ph.D.
Levon Margolin, Ph.D.
Past Issues
http://nappp.org/backissues.html
Submissions
Editor.TheClinicalPractitioner@gmail.
com
NAPPP on the Web
www.NAPPP.org
NAPPP Executive Board
John Caccavale, Ph.D.
Nick Cummings, Ph.D.
Jerry Morris, Psy.D.
David Reinhardt, Ph.D.
Howard Rubin, Ph.D.
Levon Margolin, Ph.D.
Jack Wiggins, Ph.D. (Ret)
NAPPP Advisory Board
Ward Lawson, Ph.D.
Keith Petrosky, Ph.D.
Cheri Surloff, Ph.D., Psy.D.
Sharna Wood, Ph.D.
The 1999 paper Unskilled and unaware of it: How difficulties in
recognizing one's own incompetence lead to inflated self-assessments
by David Dunning an Justin Kruger was an instant success among talk
show hosts and comedians.1 In the first few years after the paper was
published, studies started to appear in many professional journals. The
problematic aspect of incompetence, of course, is that you have a group
of people who are completely unaware of their incompetence and, when
considering the cognitive dissonance factor, they dig in their heels to
justify their position.
Clearly, it doesn't take much to see the Dunning-Kruger effect at work
in many everyday interactions. However, I would like to expand on
their work to point out a somewhat different slant on the issue. It's one
thing to study how stupid and ignorant people are and the irrational
conclusions they formulate and act upon. It's another matter, however,
when we see trained professionals and the highly educated offering
opinions and policies that make them appear like stupid people trying
to pass as smart ones. In a perverse restatement of Milton Erickson's
view of the unconscious, "They're incompetent but they don't know
they're incompetent." In an interview 2 after their paper was published,
Dunning stated,
An ignorant mind is precisely not a spotless, empty vessel, but
one that’s filled with the clutter of irrelevant or misleading life
experiences, theories, facts, intuitions, strategies, algorithms,
heuristics, metaphors, and hunches that regrettably have the look
and feel of useful and accurate knowledge.
If we look closely enough and without the rose colored glasses of our
own subjective feelings and long held beliefs, everyone, from time to
time, can articulate some really stupid connections about the world in
which we live. The Dunning-Kruger effect should not be about isolated
stupidity or the pseudo-philosophical rants by the Duck Dynasty, for
example. It should not be confined to the ranks of the less educated.
Our concern should be about those who we believe are competent and
are in a position to make or influence policies and important decisions
that affect our lives and all of society.
For example, what do we really know about the professionals upon
whom we rely to make judgments about our healthcare? What about
policymakers whose policies have the potential to produce harm? In
our present environment of the security state, what about our military
leaders? Do we know how much knowledge and upon what that
knowledge is based when their recommendations are set into action? In
regard politicians, I really do not think we are in the dark about them.
For many years we have heard and come to accept that, in politics,
ignorance is bliss. What about psychology? I haven't seen much, if
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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The Dunning-Kruger Effect
anything, about the D-K effect being applied to our
profession. To that end, I would like to offer a few
areas where I believe the D-K effect reigns supreme
in the policies and practices that we have all come
to accept as professional psychologists. Please note:
These examples are not finite.
The Belief In Evidence-Based Therapy
There is no question that striving to determine and
implement treatments that work is a needed and
important goal. But, seeking is not the issue. The
salient issue is how does one determine what is and
what is not evidence-based. This issue addresses
research design, reproducibility of results, significance
and, most importantly, clinical relevance.
As it stands, it is my contention that for psychology
determining what is an evidence-based therapy may
be as elusive as the quest for the Holy Grail. This
conclusion is not based upon a belief that the subject
matter of psychological therapy is in the realm of the
"soft" sciences. On the contrary, our subject matter is
in the realm of really hard science.
Physical and chemical research is easier to conduct
because a molecule of carbon and a ray of light can
be seen and studied similarly anywhere because
they are variables that can be manipulated because
of consistency and predictability. Human behavior,
however, is not consistent or very predictable. Also,
ethical considerations make manipulation of human
beings unacceptable. So, which science is really soft?
The research designs that must be used to determine
what is and what is not evidence-based is not available
to psychologists; yet, there are those in our profession
who seem intent on promoting something utilizing
babble not based upon a competent understanding of
the issues. Mostly, the pandering to EBT is nothing
more than trying to get reimbursement for favored
therapies.
In medicine, for example, few studies looking at
the effectiveness of medications have been able to
be reproduced. Oncology researchers who analyzed
the many efficacious cancer therapies reported that
scientists at the pharmaceutical company Amgen
could not replicate the overall majority of published
pre-clinical research studies. Only 6 out of 53 of the
most important cancer studies could be replicated
- a success rate of 11%.3 Similarly, the problem of
reproducibility is present in many other areas of
medicine. So, if evidence-based therapies are difficult
to find in medicine, what is the potential for evidencebased therapies in psychology? When having a patient
sit in a corner going through a manual is the most
exciting evidence-based therapy and having our
profession continually spew out rhetoric about it, the
Dunning-Kruger effect is a good way to address the
denial of reimbursement from insurers.
With respect to significance, for too long we have
been saddled with the rule .05 and .01 rules for
determining significance. Medicine has no problem
getting treatments approved for therapies that show
only 30% clinical significance. I contend that the
profession of psychology and its patients would benefit
greatly if we turned our focus to the more relevant and
truthful criterion embedded in clinical significance.
Our unwise commitment to statistical processes and
the "truth" that it imparts simply is not justified or
competent in evaluating clinical therapies. There is a
place for statistical significance but we should develop
guidelines that make sense and not simply bow down
to numbers that most people do not understand in
terms of relevance to patient improvement.
Lastly, what we do know about what works is related to
who is doing the treatment. The therapist variable has
been demonstrated to be the most explanatory variable
in assessing patient improvement. This one variable
is both clinically and statistically significant. I suggest
that we need to seriously consider the Dunning-Kruger
effect as another metric when looking at evidencebased therapy.
Does Accreditation Assure Quality?
Since 1940 when APA began promoting accreditation
of psychology programs psychologists, employers and
government agencies have accepted that accreditation
implies or insures quality. The APA website contains
numerous statements that they say support this claim.
Yet, there is not one single study that demonstrates
psychologists who are graduated from APA
accredited programs provide more quality services
than psychologists graduated from non-accredited
programs. There is not one study that demonstrates
graduates from APA programs are more competent,
are less likely to be disciplined or have their licenses
revoked or restricted because of incompetence.
What can be said about APA accreditation is that
graduates from APA accredited programs have more
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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The Dunning-Kruger Effect
job opportunities because APA has been successful in
convincing government agencies and other employers
that there is some value in APA accreditation.
Without further elaboration, statements about APA
accreditation and its value are simply not in the realm
of competent analyses. One reason for this lack of
evidence is that APA has not thought it necessary
to do the research to justify its claims because no
research would show that APA accreditation does
anything more than increase the tuition of psychology
programs. Until professional psychology agrees upon
a standardized program of training, as does law and
medicine and many other professions, accreditation
claims will fall under the Dunning-Kruger effect.
Licensing and The Psychology Testing Industry
Every psychologist seeking to practice must take
and successfully pass the Examination for the
Professional Practice in Psychology (EPPP). The
EPPP was developed by the ASPPB to assist the states
when evaluating applicants in granting licenses to
psychologists. Clearly, the assumption is that there
is a relationship between minimal competence and a
passing grade on the test. On its website the ASPPB
states that the EPPP has high reliability. Yet, while
there are some studies that seek to provide reliability
and content validation to the EPPP, they report
inconsistency and not very encouraging results about
either the test's reliability, validity or of its contents.4-5
This is important because deep in the culture of
professional psychology is this strong belief in
testing as a way to assure minimal competency. As
psychologists we are so into this belief that we not only
spend tens of millions of dollars in paying to take the
EPPP, but also untold millions more paying companies
preparing us to pass the exam. While I haven't done a
study on a state-by-state pass rate for the EPPP or any
historical analysis, the ASPPB website states that it is
a myth that there is a low pass rate on the exam. I do,
however, have the latest results for California.
In their latest newsletter, the California BOP states
that the pass rate for the 2013-2014 fiscal year was
62%.6 That doesn't seem like an overwhelmingly
high pass rate. In fact, since the EPPP purports to
test the minimal knowledge that a doctoral level
psychologist should possess, one may conclude that
the schools preparing these psychologists are doing
a really poor job. We may also conclude that APA
accredited programs and their standards have little
relationship to quality education and training. Lastly,
we might conclude that the EPPP is really an expensive
but relatively worthless way to evaluate minimal
competence. Perhaps all three conclusions are correct.
The Dunning-Kruger effect here is not about stupid
people or only incompetence. It's also about rigidity
of institutions and organizations to change and admit
failure. It's about repeating beliefs not supported by
the facts. This is classic Dunning-Kruger. It's about
economics both at the educational level, training
level, the organization level, and the relationship
between bloated salaries earned by staff in professional
organizations and the associated legions of others
making money off unsupported validity and reliability
of the EPPP. I might add that psychology is not the
only profession that needs to evaluate its testing
mythology. Recently, the deans of some of the most
prestigious law schools are questioning the reliability
and validity of having law graduates take and pass the
state bar to practice law. They see the bar exam as not
representing the knowledge attorneys need to practice
or more predictive than successfully completing law
school.
To visualize just how absurd are the claims that the
EPPP is related or even necessary for licensure, the
following table may provide some guidance.
Establishing Minimal Competence
for Licensing Psychologists
THIS or THOSE plus THIS
1. 4-6 years post graduate study. Scored a minimum
2. Successfully passed all course- of 70% on the EPPP
work with a 3.0 or better.
3. Successfully submitted a
dissertation or similar
research project.
4. Successfully defended the
dissertation.
5. Successfully passed content
examinations.
6. Successfully completed a
minimum of 3000 hours of
supervised practice.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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The Dunning-Kruger Effect
Concluding Statements
In conclusion, David Dunning's statement should
be very worrisome to psychologists when evaluating
what comes out of those in psychology who decide
what and how knowledge in psychology should be
acquired, practiced, regulated and evaluated. We must
really look at the rational behind every claim made by
those who purport to represent our interests and the
interests of our patients.
References
1. Kruger, J. & Dunning, D. (1999). Unskilled and
unaware of it: How difficulties in recognizing one's
own incompetence lead to inflated self-assessments.
Journal of Personality and Social Psychology, Vol
77(6), Dec 1999, 1121-1134.
2. David Dunning. http://www.psmag.com/healthand-behavior/confident-idiots-92793
3. Begley, C & Ellis, LM. (2012). Drug development:
Raise standards for preclinical cancer research. Nature
483, 531–533 (29 March 2012) doi:10.1038/483531a.
4. Sharpless, Brian A.; Barber, Jacques P.(2009. The
Examination for Professional Practice in Psychology
(EPPP) in the era of evidence-based practice.
Professional Psychology: Research and Practice, Vol
40(4), Aug 2009, 333-340. http://dx.doi.org/10.1037/
a0013983
5. Sharpless, Brian A.; Barber, Jacques P. (2013).
Predictors of program performance on the
Examination for Professional Practice in Psychology
(EPPP). Professional Psychology: Research and
Practice, Vol 44(4), Aug 2013, 208-217. http://dx.doi.
org/10.1037/a0031689
6. The California Board of Psychology. Issue #4.
Winter 2015.
National Alliance of
Professional Psychology
Providers
Failure
To
Serve
A White Paper on The Use of
Medications As A First-Line
Treatment
And Misuse In Behavioral
Interventions
This report was prepared by:
The National Alliance of Professional
Psychology Providers
http://www.nappp.org/
[email protected]
The Executive Summary can be read at
http://nappp.org/Exec_summary.pdf
Read the complete report at
http://nappp.org/White_paper.pdf
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
5
Mental Health Care:
Lessons Learned and a Look to the Future
By Jerrold Pollak, Ph.D.
Introduction
Impressive advances have been made in the
understanding and treatment of mental health
disorders since the start of this century (Lambert
& Archer, 2006). Despite the ongoing problem of
stigma connected to having a mental health condition
(Corrigan, 2014), there is greater societal acceptance of
the ubiquity of mental illness across the life span, and
enhanced appreciation of the benefits of mental health
care. In increasing numbers, people are seeking mental
health services (Moran, 2014), and at present, there
are a substantial number of licensed mental health
practitioners (Hamp, Stamm, Christidis & Nigrinis,
2014). Why is it then that the mental health of the
nation seems worse than ever and mental health care
continues to be so inadequate for so many?
The reasons for this situation are complex and multifaceted and reflect a host of institutional, systemic and
socio-cultural factors, including the philosophies and
practices of the health insurance and pharmaceutical
industries as well as the education/training of mental
health professionals.
This article reviews some of the structural problems
that adversely affect the delivery of effective and high
quality mental health care. It also addresses mistaken
assumptions and missteps that have long influenced
the mental health care field. Recommendations are
offered to improve the education/training of mental
health clinicians and enhance the efficiency and
efficacy of services.
Lack of Integration of Health Care Services
For too many patients mental health care is
woefully insufficient due to a poorly integrated
system of health care. Hardest hit are “dual” or
“multi-diagnosis” patients. These are consumers
with significant comorbidity - one or more serious
psychiatric conditions coupled with significant medical
conditions (often chronic pain) and/or substance
abuse problems (Sederer & Sharfstein, 2014). These
clinically complicated patients may have to see several
practitioners in different settings to address their
many difficulties. In most instances, however, this
proves impossible due to obstacles like insurance
coverage, access to services and related problems
navigating a splintered system of health care. Even
when patients are successful in receiving appropriate
services, effective communication and coordination
of care between practitioners, located in autonomous
milieus, are more the exception than the rule.
Education/Training of Mental Health
Professionals
For the most part, the education/training of bachelor’s
and master’s level mental health professionals involves
unimpressive criteria for admission-matriculation
as well as a lack of a standardized curriculum and
practicum/internship training across programs. In
the case of masters level clinicians, examinations for
state licensure have no established validity for clinical
practice.
Many of these programs have a lopsided emphasis
on the teaching of multiculturalism and social justice
while giving short shrift to medical/neuropsychiatric
bases of behavior. Consequently, there is little, if
any, systematic instruction and training in core
competencies critical for effective clinical practice. This
includes how to conduct a mental status examination
and arrive at a working differential diagnosis
(including possible medical contributions to the
patient’s mental health difficulties); how to complete a
comprehensive risk assessment and the judicious use
of psychological screening tests to bolster these and
other critical skills for “real world” intervention.
Doctoral level education/training in professional
psychology, is more rigorous (Padover, 2014).
However, it suffers from many of the same problems
that characterize subdoctoral education (Morris,
2014).
Entry Level Clinical Practice
Once in public sector community settings, newly
minted clinicians are saddled with huge caseloads
and paperwork demands and spend as much time
“treating the paper” as “treating the patient.” Case files
are enormous and frequently do not include updated
reviews/summaries for many patients in long-term
continuous or recurrent services. Well intentioned,
albeit inexperienced, clinicians become involved in
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Lessons Learned and a Look to the Future
cases with little appreciation/understanding of their
patients’ histories. This is particularly disconcerting
when cases involve significant histories of selfharm, danger to others and/or impaired self- care.
Supervision and other institutional monitoring and
oversight are typically spotty and incomplete.
The low pay and unreasonable productivity demands
of these jobs result in frequent staff turnover. Systems
quickly lose conscientious and talented early career
clinicians who leave these settings after a few years
only marginally better off financially than the indigent
patients they were hired to help.
The high turnover of clinical staff runs up agency
costs and lowers staff morale. It also results in
“iatrogenic effects” for many patients - unintended
negative consequences of health care system policies
and clinical interventions. This is especially true
for persons with heightened attachment and loss/
separation issues who constitute a substantial
percentage of consumers seen in public sector mental
health systems.
For decades now mental health administrators (who
are generally paid considerably better than the nonmedically trained clinical staff that they employ)
have seemingly been at a loss regarding how to retain
promising staff and improve this sorry state of affairs.
Role of Clinical Psychiatry
Clinical Psychiatry remains the mental health
discipline with the most influence, prestige and
financial remuneration. This profession has undergone
dramatic changes since the late 1980’s engendered
by the advent of managed care and the boom in
the psychopharmaceutical industry. Psychiatrists
trained since that time work nearly exclusively
as diagnosticians and psychopharmacologists
with virtually all psychosocial care, including
psychotherapy, delegated to non-medically trained
practitioners: Mental health counselors, social workers
and psychologists.
There is a dearth of psychiatrists nationwide to
address the steady increase of persons in need of
psychopharmacologic services (Carlat, 2010). This has
led to the ascent of advanced practice registered nurses
(APRN), physician’s assistants and family physicians
practicing psychopharmacology to fill the void
(Caccavale, 2014). None of these newer prescribing
groups have much in the way of training in the
psychosocial aspects of care and, in the case of family
physicians and physician’s assistants, possess little, if
any, formal education and training in mental health
evaluation/treatment including psychopharmacology.
The Emergence of “Split-Treatment”
These developments in mental health service delivery
have given rise to the “split treatment” model (Meyer,
2012). Within this treatment approach psychiatrists
and other “medication prescribers” limit their role to
psychopharmacologic treatment and non-medically
trained clinicians address the psychosocial needs of
patients. There are many problems with this divided
model of service delivery, not the least of which is
that it exacerbates an already anemic and fragmented
system of care.
Divided treatment within the same health care setting
is sometimes fairly workable as practiced in some
community mental health centers and medical centers.
However, it is frequently undermined by high staff
turnover, which limits the longevity of the working
relationships between the providers as well as between
the providers and their patients.
Many patients decline to enter into this arrangement
or soon drop out of it. They may forgo services
altogether or settle on monotherapy: becoming
a “medication” or a “counseling/psychotherapy”
only patient despite the evidence that combination
treatment produces generally better outcomes
than monotherapy, particularly for anxiety and/or
depression, which are the most frequently occurring
mental health conditions across the lifespan (Cuijpers,
Van Straten & Warmerdam, 2009).
Based on the “fifteen minute” medication check, the
consultation model now enshrined in public sector
mental health systems across the country (and in many
private practice settings as well), “medication only”
patients may spend as little as an hour a year in direct
“face to face” treatment.
On the flip side, other patients, some with strong
ideological convictions about the presumptive evils
of psychopharmacology (beliefs occasionally shared
by their counselors/therapists) languish and, in some
instances, deteriorate in psychosocial treatment
despite having medication responsive psychiatric
conditions.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Lessons Learned and a Look to the Future
Over Treatment and the Problem of Iatrogenic
Effects
paucity of marketable job skills and little structure and
meaning/purpose in their lives.
Mental health clinicians know little about iatrogenic
effects, despite the significant clinical and research
literature on this subject (Barlow, 2010). For decades
the overriding belief shared by the mental health
professions was that just about any treatment is better
than no treatment, more treatment is almost always
better than less and longer/sustained treatment is
better than briefer and/or more episodic care.
Rating Scale Assessment and Psychological/
Neuropsychological Testing
There have been many casualties of this view.
Famously, this includes persons with borderline
personality disorder who often became more
symptomatic and unstable with intensive individual
treatment, especially highly transference-based
psychodynamic psychotherapy (Seinfeld, 2002). It
also includes patients in interminable supportive
psychotherapies with nebulous goals with no
demonstrable benefit.
Fortunately evidence-based practice has come to the
fore (Drake, Lynde & Merrens, 2005). Starting in the
1990’s this has included the development of briefer
and targeted evidence-based interventions to address
a wide range of conditions (including borderline
personality disorder): Cognitive- Behavioral Therapy,
Dialectical Behavioral Therapy/DBT, Acceptance/
Mindfulness, Eye Movement Desensitization and
Reprocessing/EMDR and Positive Psychology.
However, lessons learned from the domain of
psychosocial intervention have not always carried over
that well to psychopharmacology. Witness the practice
of poly-psychopharmacology, wherein patients on a
seemingly endless “magical misery tour” of multiple
medications coupled with frequent medication
adjustments due to poor response and/or intolerable
side effects in an often futile effort to stabilize behavior
and mood (Hoffman, Schiller, Greenblatt & Losifescu,
2011). Though clearly not the standard of care, this
approach continues despite the paucity of research
support for its validity particularly for borderline
patients and for patients with and without borderline
personality disorder who have histories of significant
psychosocial trauma including children with reactive
attachment disorder (Gunderson, 2011). Efforts also
continue to try to “medicate away” existential problems
like loneliness and social disconnection among the
many mental health patients who live alone in substandard housing with limited formal education, a
There is extensive evidence-based literature on
the clinical utility of brief patient and informant
questionnaires/rating scales for establishing symptom
severity and to assist in differential diagnosis,
treatment planning and evaluation of treatment
process/outcome (Blais, 2011). Yet few clinicians,
outside of a relatively small number of psychologists,
have a good working familiarity with these instruments
and routinely incorporate them into their work
(Zimmerman, 2014).
Moreover, many mental health and primary
care practitioners have scant knowledge of the
indications and contraindications for psychological/
neuropsychological testing despite the strong evidence
base supporting the clinical utility of this practice for
clarifying the clinical status and treatment needs of
patients (Bram & Peebles, 2014; Schwarz, Roskos &
Grossberg, 2014).
Although for decades an enduring practice niche for
psychologists, few psychologists (especially those
who practice in rural areas) have solid training and
experience in testing and specialize in this area
of clinical care. This disconcerting trend is due
primarily to the low reimbursements and restrictive
authorization policies of managed care companies.
Psychiatrists and other medical specialists often want
their patients tested and complain that they are unable
to find appropriately trained psychologists who can
provide this service in a timely manner. However,
the medical community has done nothing to advance
the cause of testing by advocating with insurance
companies for greater access to and better payments
for this consultative diagnostic service. Rather, they
have left it entirely to psychologists to fight this battle
with third party payers. Predictably, without advocacy
by the medical community, professional psychology
has had only limited success in rectifying this situation.
Inpatient Treatment
Mental health care on an inpatient basis has its own
set of problems. Due to bed availability shortages
in many parts of the country patients who warrant
hospitalization, are agreeable to a psychiatric
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Lessons Learned and a Look to the Future
admission and have workable insurance can wait
as long as a day or more in hospital emergency
departments for a bed while staff work assiduously to
try to secure a transfer to an inpatient mental health
facility.
For involuntary patients (those who are admitted to
inpatient mental health facilities against their will via
the civil commitment process) the wait for a bed in
an emergency department can be as long as a week
in some states. For several years now, “Psychiatric
Boarding,” as this practice is termed, has become
widespread across the country (Thomas, 2014).
Over the last decade or so, inpatient stays of several
weeks have withered, in many cases, to a few days due
to insurance company authorization practices. This
results in premature discharges with patients leaving
inpatient settings with, at best, modest improvement
in their symptoms and everyday functioning. In some
cases patients spend more time waiting in emergency
departments for a psychiatric bed than they do in
the inpatient mental health service to which they are
eventually transferred. Perhaps the most concerning
scenario involves patients who languish in emergency
departments only to be discharged because of an
inability to find an appropriate bed.
Persons who are admitted to inpatient mental health
services due to concern about danger to self (the most
common reason for inpatient admissions) are often
as unsafe and, in some instances, may be more at risk
for self-harm at the time of discharge than prior to
admission due to short stays. Research indicates that
many patients discharged from inpatient mental health
units do not transition quickly, if at all, to outpatient
care to consolidate whatever gains were made from
their hospitalization (Olfson, Marcus & Bridge, 2014).
They remain at elevated risk for relapse (including selfharm) and need for readmission due to the brevity of
stays and problems accessing outpatient follow-up care
in a timely manner.
Adding insult to injury, continuity of care suffers for
patients needing early rehospitalization as the facility
which had recently discharged them often has no beds.
This compels the search for another inpatient service
with no history with these patients.
The better news is that the pendulum may be swinging
back in the direction of greater bed availability and
more reasonable hospital stays to address these
shortages (Souter, 2014).
Alternatives like residential treatment are few and far
between for patients in need of longer-term continuous
care and is generally only available to financially
well off patients and their families who can afford to
self-pay. However, pressure is building for insurance
companies to cover this level of care for patients
meeting specific criteria (Moran, 2014).
Patient Centered Medical Homes and
Integrated Health Care
In the years ahead, the establishment of patient
centered medical homes where primary medical
care as well as mental health and substance abuse
services are co-located or available in neighboring
transportation-friendly locales and linked by an
electronic medical record can be expected to enhance
consumer and provider satisfaction as well as improve
treatment compliance and outcomes (Novotny, 2014).
Patient-centered medical homes could also save money
by reducing overhead costs for outpatient care and
lower rates of inpatient psychiatric admissions for
patients who are “crisis-prone” and/or experience
frequent exacerbations of major mental illness.
“Telepsychiatry,” expanded coverage under the
Affordable Care Act and, perhaps a single payer system
specifically for mental health and substance abuse
care, may also help to augment the effective delivery
of mental health care. However, full implementation
of such structural reforms is likely many years away
(Miller, Peterson, Burke, Phillips & Green, 2014).
A New Model for Education/Training
These conceptually appealing ideas do not solve the
problems wrought by the plethora of separate and
discrete mental health professions each with their own
education/training requirements, ethics/professional
standards, proficiencies/specialties and sociopolitical
agendas. They also do not address the ever-widening
gap in knowledge, skill, and income between medical
and non-medical providers.
In the years ahead patients will increasingly be seen
in primary care settings for their mental health care.
Imagine a situation where, in one appointment,
they could consult with one clinician who would
have the expertise to provide, as clinically indicated,
psychopharmacologic treatment, counseling/
psychotherapy and psychological test screening.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
9
Lessons Learned and a Look to the Future
There would need to be a radical change in the
education/training of mental health professionals to
bring about this commonsense approach to patient
care. In effect, this would mean the education/training
of one mental health professional at two levels: the
master’s level and the doctoral level: three years
of training for the master’s degree and six years of
training for the doctoral degree. Both groups would
be able to offer the three clinical services cited above
but would be required to specialize in one of two broad
age groupings – children/adolescents or adults/older
adults and also pass competency-based examinations
in these three areas of clinical practice germane to the
age group for which they received training.
Both masters and doctoral level clinicians would
provide psychopharmacologic care. Masters level
clinicians, though, would work with a limited
formulary involving cases meeting specific criteria with
monitoring/supervision by doctoral level clinicians.
Ordinarily, preparation for graduate study would
require a bachelor’s degree with a major in psychology
and a minor in the biological sciences or the reverse.
Clearly, this model would not eliminate the need
for split or even multiple provider treatment for
complicated cases. For example, patients with
severe and persistent mental illness accompanied by
significant medical morbidity and substance abuse.
In this regard a multi-disciplinary treatment team is
likely to work best for these cases (Morris, 2014). Yet,
for a sizable number of patients this training paradigm
would help to ameliorate a number of the dilemmas
currently plaguing mental health care. It can be
expected to streamline the delivery of services, build
stronger treatment relationships between patients
and providers, strengthen the transition to integrated
care and probably boost provider salaries while also
lowering costs. Overall, it would create something
sorely lacking in the current health care climate: a
cadre of mental health clinicians who are truly well
trained in the biopsychosocial model of mental health
disorders (Greenberg, 2014). These clinicians could
“hit the ground running” within primary care including
emergency departments and other urgent care settings.
A variant of this model may slowly gain traction in
the near future. For example, the development of the
doctoral program in behavioral health at Arizona State
University (ASU online). Ultimately though, graduate
education in medical psychology, at the masters and
doctoral levels, is considered the best path to pursue
for training based on this paradigm.
Reform in Education/Training and Service
Delivery
In the absence of the establishment of a new
education/training model and the likely gradual
evolution towards an integrated system of mental
health and medical care, cross-over training is needed
for all of the mental health professions when it
comes to the use of rating scales for assessment and
treatment process/outcome as well as the development
of a solid knowledge base and standardized skills in the
evaluation and treatment of substance abuse (Pollak,
2014).
The training of non-medical health clinicians in
particular should involve a much greater emphasis
on medical literacy. This would include a focus on
the signs/symptoms of possible neurodevelopmental
and medical contribution to psychiatric symptoms
particularly the effects of neurocognitive disorders,
medications and other substances on affect, mood and
behavior (Pollak & Miller, 2011; Reinhardt, 2014). It
would also involve knowledge and skill development in
the psychosocial aspects of chronic medical conditions
(Belar & Deardorff, 2009; Morris, 2014). In addition,
formal training in the evaluation of mental status and
risk assessment ought to be required in all graduate
programs (Smith, 2014). The content of licensure
examinations for entry level practice should strongly
reflect this emphasis on medical literacy.
Conclusion
In response to the surge of opiate and other substancerelated deaths, non-suicidal self-harm, suicides, and
recurrent rage killer sprees in recent years, there has
been a strong push for the education/training of more
mental health clinicians. Shortages clearly exist in
geriatrics and other areas of clinical practice. However,
simply turning out more non-medically trained mental
health professionals may be nothing more than,
“rearranging the deck chairs on the Titanic,” as it
does not address the many structural problems cited
above. Less is more could well be the case i.e., it may
make considerably more sense to put the lion’s share
of effort, time and funding into integrated health care
and the training of better and more effective medically
informed mental health practitioners than, simply
increasing the numbers of practitioners within the
current system of education/training.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Lessons Learned and a Look to the Future
current system of education/training.
Going back to basics is also indicated. This involves
expanding services: crisis beds, day hospital, and
community residences, all of which have eroded in
many areas of the country and which can be cost
effective alternatives to inpatient admission.
References
Barlow, D.H. (2010). Negative effects from
psychological treatments. American Psychologist, 65, 13-20.
Belar, C.D. & Deardorff , W.W. (2009). Clinical health
psychology in medical settings: A practitioner’s guidebook.
Washington, DC: American Psychological Association Press.
Blais, M. A. (2011). A guide to applying rating scales in
clinical psychiatry. Psychiatric Times, November, 58-62.
Bram, A. D. & Peebles, M.J. (2014). Psychological testing
that matters. Washington, DC: American Psychological
Association Press.
Caccavale, J. (2014). Prescription authority for
psychologists: Is it our values or shortsightedness that keeps
us from being primary care mental health providers. The
Clinical Practitioner, 9 (2), 1-3.
Carlat, D. (2010). 45, 000 psychiatrists anyone? Psychiatric
Times, 27 (8), 1 and 3-4.
Corrigan, P. (2014). The stigma of disease and disability:
Understanding causes and overcoming injustices.
Washington, DC: American Psychological Association Press.
Cuijpers, P. Van Straten, A. & Warmerdam, L. (2009).
Psychotherapy versus the combination of psychotherapy and
pharmacotherapy in the treatment of depression: A metaanalysis. Depression and Anxiety, 26, 279- 288.
Doctor of behavioral health program, ASUonline.asu.edu/
dbh.
Drake, R.E., Lynde, D.W. & Merrens, M.R. (Eds.). (2005).
Evidence –based mental health practice: A textbook. W.W.
Norton , NewYork, NY.
Greenberg , R. P. (2014). The return of psychosocial
relevance in a biochemical age. The Register Report, 40,
10-16.
Gunderson, J. G. (2011). Clinical practice: Borderline
personality disorder. New England Journal of Medicine, 364
(21), 2037-2042
Hamp, A., Stamm, K., Christidis, P. & Nigrinis, A. (2014).
What proportion of the nation’s behavioral health providers
are psychologists. APA Monitor, 45 (8), 18.
Hoffman, D.A., Schiller, M., Greenblatt, J.M., & Iosifescu,
D.V. (2011). Polypharmacy or medication washout: An old
tool revisited. Neuropsychiatric Disease and Treatment, 7,
639- 648.
Lambert, M. J., & Archer, A. (2006). Research findings
on the effects of psychotherapy and their implications for
practice . In C.D. Goodheart , A.E. Kazdin & R. J. Steinberg
(Eds.) , Evidence –based psychotherapy. Where practice and
research meet (pp. 111- 130). Washington, DC: American
Psychological Association Press.
Meyer, D.J. (2012). Split treatment: Coming of age. In R.I.
Simon and R.E. Hales (Eds.) Textbook of suicide assessment
and management (2nd ed., pp. 263-279), Washington, DC:
American Psychiatric Publishing.
Miller, B.F., Petterson, S., Burke, B.T., Phillips, R. L., &
Green, L.A. (2014). Proximity of providers: Colocating
behavioral health and primary care and the prospects for an
integrated work force. American Psychologist, 69, 443- 451.
Moran, M. (2014 a). Mental health service use increasing in
multiple settings. Psychiatric News, 49 (16), 17
Moran, M. (2014 b). Patients score parity victories in two
states. Psychiatric News, 49 (16), 1, 14 and 35.
Morris, J. (2014). An outdated health care system:
Problems, barriers, blockades and solutions. Archives of
Medical Psychology, 6 (1), 36-54.
Novotney, A. (2014). Psychology’s role in patient-centered
medical homes. APA Monitor, 45 (10), 38- 40.
Olfson, M., Marcus, S.C., & Bridge, J.A. (2014). Focusing
suicide prevention on periods of high risk. Journal of the
American Medical Association, 311 (11), 1107-1108
Padover, G. (2014). The interface between psychologists and
medical psychology. The Clinical Practitioner, 9 (2), 9- 12.
Pollak, J. (2014). Mental health treatment and co-occurring
cannabis use disorders. Counselor Magazine, 15 (3), 50-55.
Pollak, J. & Miller (2011). Mental disorder or medical
disorder? Clues for differential diagnosis and treatment
planning. Journal of Clinical Psychology Practice, 2, 33-40.
Reinhardt, D. (2014). Drugs that cause psychological
symptoms. The Clinical Practitioner, 9 (2), 5- 6
Schwarz, L., Roskos, P.T., & Grossberg, G. T. (2014).
Answers to 7 questions about using neuropsychological
testing in your practice. Current Psychiatry, 13, 33-39.
Sederer, L. I. & Sharfstein, S.S. (2014). Fixing the troubled
mental health system. Journal of the American Medical
Association, 312 (127) , 1195- 1196.
Seinfeld, J. (2002). A primer for handling the negative
therapeutic reaction. New York: NY, Jason Aronson .
Smith, B.L. (2014). Psychologists need more training in
suicide risk assessment. APA Monitor, 45 (4), 42.
Souter, C. R. (2014). Inpatient care to expand. New England
Psychologist, 22 (8), 1, 12 .
Thomas, J. (2014). Washington State ordered to halt
‘psychiatric boarding.’ National Psychologist, 23 (6), 1 and 3
Zimmerman, M. (2014). Measuring outcome in clinical
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A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Nicholas A. Cummings: Psychology's
Provocateur
This book is not only a biography of professional psychology's innovator and visionary.
It is a book that documents the long history and struggle of professional psychology. Dr.
Nicholas Cummings, "Nick" to so many of his friends, has been at the front lines of
taking and making the fight for psychologists to be recognized and included in the
healthcare system. Nick's biography is the biography of every psychologist. It is our
history and, absent the accomplishments of Nick Cummings, there is no doubt that
professional psychology would not exist.
The Cummings Foundation is making copies of the book FREE of charge to TCP readers
who would like one for the $5.00 shipping charge, only. If you would like your free copy
of the book, email Linda Goddard at [email protected] and she will arrange to have
the book sent to you. A faster way to get your copy is to send a check for $5.00 to:
Linda Goddard
Cummings Foundation For Behavioral Health
4781 Caughlin Parkway
Reno, NV 89519
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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What others are saying… from CCHR International
Finally—A Bill To Help Foster Care Children, Not Big Pharma
By Kelly Patricia O’Meara
In light of a San Jose Mercury News investigation
“Drugging Our Kids” exposing the massive
psychotropic drugging of children under California’s
foster care system, which found nearly 25% of
adolescents in California’s foster care system are
prescribed mind-altering psychotropic drugs,
lawmakers are now understanding the urgency of
legislation to curb this abusive practice.
In California, Assemblyman Mike Gipson (64th
District) has submitted language, amending existing
legislation (AB 1067), providing for specific protections
from psychiatric/medication abuse of children under
state care. Supporting groups, such as the Citizens
Commission on Human Rights (CCHR) say it is the
first legislation to serve foster children rather than
psychiatric pharmaceuticals. The California branch of
the NAACP has written to state legislators in support
of the bill, saying it would “ensure that foster children
in California are afforded the same rights to refuse
psychotropic medication which are given youths
confined in a state juvenile facility.”
To have a prescribing doctor disclose any financial
ties he or she may have to pharmaceutical companies.
The latter is in response to the increasing
pharmaceutical influence on prescribing physicians.
It was revealed by Mercury News that between 20102013 drug makers spent more than $14 million
marketing to California doctors treating foster care
children and those doctors with high prescription
rates typically received the most funding. Gipson’s
legislation would force physicians prescribing to foster
children to disclose all pharmaceutical funds received,
potentially disbarring these doctors from treating
foster care children.
CCHR News March 20, 2015
Ed: CCHR asks that we support their Petition to
Prevent the Dangerous Psychotropic Drugging of
California’s Foster Care Youth which may be found at
https://www.change.org/p/california-legislators-andpolicymakers-prevent-the-dangerous-psychotropicdrugging-of-california-s-foster-care-youth
According to Gipson, Assembly Bill 1067 will work
towards necessary improvements, “which include
making sure our foster children have a say about what
medication they are given.”
Assemblyman Gipson’s legislation would be an
important step in correcting the wholly inadequate
protections within the system. Specifically,
Assemblyman Gipson’s legislation addresses informed
consent issues and rights for minors and non-minors
in foster care, including:
To be informed of the risks and benefits of
psychotropic medication.
To appear before the judge determining if
psychotropic medication should be administered,
with an advocate of his or her choice, and state that
he or she objects to any recommendation to prescribe
psychotropic medication.
The availability to refuse the administration of
psychotropic drugs.
NAPPP White Paper Available
NAPPP has prepared an 80 page document
against using medications as a first-line
treatment for behavioral disorders. The
report details the lack of science behind using
medications as first-line treatments and their
misuse by physicians when treating behavioral
disorders. The executive summary of the paper
can be read at http://www.nappp.org/Exec_summary.
pdf
The link to the full report is contained in the
executive summary.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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What others are saying… Practice Guideline from the British Medical Journal
Diagnosis and management of depression in children and young
people: summary of updated NICE guidance
Highlights
•
There is little clear evidence to favour one
psychological therapy over another for the
treatment of depression in children and young
people. Clinicians should discuss this uncertainty
when recommending treatments
•
For initial treatment of moderate to severe
depression in young people (12-18 years),
antidepressants and psychological therapy may be
started concurrently as an alternative to offering
a trial of psychological therapy first and starting
antidepressants only if this trial is unsuccessful
Depression affects around 2.8% of children under
the age of 13 and 5.6% of 13-18 year olds. Effective
treatment is important because persistent depression
is associated with serious complications, including
poor school performance and social functioning,
recurring depression in adulthood, and suicide.
This article summarises recommendations from
the updated National Institute for Health and Care
Excellence (NICE) guideline on depression in children
and young people. The update had a narrow remit—
only recommendations on the choice of psychological
therapy and the combination of antidepressant
treatment with psychological therapy were considered.
Recommendations
NICE recommendations are based on systematic
reviews of best available evidence and explicit
consideration of cost effectiveness. Where the
evidence was minimal, recommendations in the
original guidance were based on the guideline
development group’s experience and opinion of what
constitutes good practice. Changes to the original
recommendations were based on evidence from
updated systematic reviews on clinical and cost
effectiveness. Evidence levels for the recommendations
are given in italic in square brackets.
Assessment and detection
When assessing a child or young person with
depression, routinely consider and record in the
patient’s notes potential comorbidities and the social,
educational, and family context for the patient and
family members. This information should include
the quality of interpersonal relationships between
the patient and other family members and between
the patient and his or her friends and peers. [Based
on the experience and opinion of the 2005 guideline
development group (GDG).]
Healthcare professionals in primary care, schools, and
other relevant community settings should be trained to
detect symptoms of depression and to assess children
and young people who may be at risk of depression.
Training should include the evaluation of recent and
past psychosocial risk factors, such as age; sex; family
discord; bullying; physical, sexual, or emotional abuse;
comorbid disorders, including drug and alcohol use;
and a history of parental depression. They should also
be aware of the natural course of single loss events; the
importance of multiple risk factors; ethnic and cultural
factors; and factors known to be associated with a
high risk of depression and other health problems,
such as homelessness, refugee status, and living in
institutional settings. [Based on the experience and
opinion of the 2005 GDG.]
In assessing a child or young person with depression,
always ask the patient and the parent(s) or carer(s)
directly about the child or young person’s alcohol and
drug use, any experience of being bullied or abused,
self harm, and ideas about suicide. Offer the young
person the opportunity to discuss these issues initially
in private. [Based on the experience and opinion of the
2005 GDG.]
If a child or young person with depression presents
acutely having self harmed, immediate management
should follow a previous NICE guideline that applies
to children and young people, paying particular
attention to the guidance on consent and capacity.
Further management should then follow the current
depression guideline. [Based on the experience and
opinion of the 2005 GDG.]
Assess and manage comorbid diagnoses and
developmental, social, and educational problems,
either in sequence or in parallel with treatment for
depression. Where appropriate this should be done
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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NICE Guidance on depression
through consultation and alliance with a wider
network of education and social care. [Based on nonrandomised studies.]
Pay attention to the possible need for parents’ own
psychiatric problems (particularly depression) to be
treated in parallel if the child or young person’s mental
health is to improve. If such a need is identified, a
plan for obtaining such treatment should be made,
bearing in mind the availability of adult mental
health provision and other services. [Based on nonrandomised studies.]
Child and Adolescent Mental Health Services
(CAMHS) tier 2 or 3 should work with health and
social care professionals in primary care, schools,
and other relevant community settings to provide
training and develop ethnically and culturally
sensitive systems for detecting, assessing, supporting,
and referring children and young people who are
depressed or at high risk of becoming depressed. (Tier
2 services comprise CAMHS specialists working in
community and primary care settings; tier 3 comprises
a multidisciplinary team or service working in a
community mental health clinic or child psychiatry
outpatient service.) [Based on the experience and
opinion of the 2005 GDG.]
Make training opportunities available for CAMHS
professionals to improve the accuracy of diagnosing
depressive conditions. The existing interviewer based
instruments (such as Kiddie-Sads (K-SADS) and child
and adolescent psychiatric assessment (CAPA)) could
be used for this purpose but will require modification
for regular use in busy routine CAMHS settings.
[Based on the experience and opinion of the 2005
GDG.]
Psychological therapies
Psychological therapies used in the treatment of
children and young people should be provided by
trained child and adolescent mental healthcare
professionals. [Based on non-randomised studies.]
Discuss the choice of psychological therapies with
children and young people and their family members
or carers (as appropriate). Explain that there is no
good quality evidence that one type of psychological
therapy is better than others. (New recommendation.)
[Based on low quality randomised controlled trials
(RCTs).]
Mild depression
Do not prescribe antidepressant drugs as initial
treatment in children and young people. [Based on
RCTs and the experience and opinion of the 2005
GDG.]
After up to four weeks of watchful waiting, offer
individual non-directive supportive therapy, group
cognitive behavioural therapy (CBT), or guided self
help for a limited period (two to three months) to
all children and young people with continuing mild
depression and no serious comorbid problems or
signs of suicidal ideation. This could be provided by
appropriately trained professionals in primary care,
schools, social services, and the voluntary sector or in
tier 2 CAMHS. (Reviewed 2015, unchanged.) [Based
on low quality RCTs and the experience and opinion
of the 2005 GDG.]
Moderate to severe depression
Offer children and young people a specific
psychological therapy (individual CBT, interpersonal
therapy, family therapy, or psychodynamic
psychotherapy); it is suggested that this should be of at
least three months’ duration. (New recommendation.)
[Based on low quality RCTs and the experience and
opinion of the 2005 GDG.]
Do not offer antidepressant drugs to a child or young
person except in combination with a psychological
therapy. Make specific arrangements for careful
monitoring of adverse drug reactions, as well as for
reviewing mental state and general progress—for
example, weekly contact with the child or young
person and their parent(s) or carer(s) for the first four
weeks of treatment. The precise frequency will need to
be decided on an individual basis and recorded in the
notes. If psychological therapies are declined, drugs
can still be given, but because the young person will
not be reviewed at psychological therapy sessions, the
prescribing doctor should closely monitor the child
or young person’s progress on a regular basis and
focus particularly on emergent adverse drug reactions.
(Reviewed 2015, unchanged.) [Based on moderate to
low quality RCTs and the experience and opinion of
the 2005 GDG.]
For initial treatment in young people (12-18
years), consider combined therapy (fluoxetine
and psychological therapy) as an alternative to
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
15
NICE Guidance on depression
psychological therapy followed by combined therapy
(see next recommendation). Note that use of fluoxetine
for the treatment of depression in young people
without an unsuccessful trial period of psychological
therapy is outside of the licensed indications. (New
recommendation.) [Based on moderate to low quality
RCTs.]
If depression in a child or young person does not
respond to psychological therapy after four to six
treatment sessions, undertake a multidisciplinary
review. [Based on the experience and opinion of the
2005 GDG.]
After multidisciplinary review:
-If the child or young person’s depression is not
responding to psychological therapy because of
coexisting factors, such as comorbid conditions,
persisting psychosocial risk factors (for instance
family discord), or parental mental ill health, consider
alternative or additional psychological therapy for
the parent or other family members, or alternative
psychological therapy for the patient [Based on the
experience and opinion of the 2005 GDG.]
-Offer fluoxetine if depression in a young person (1218 years) is unresponsive to a specific psychological
therapy after four to six sessions. Note that
fluoxetine is the only antidepressant licensed for
use in depression in young people (Reviewed 2015,
unchanged.) [Based on moderate to low quality RCTs
and the experience and opinion of the 2005 GDG.]
-Cautiously consider fluoxetine if depression in a child
(5-11 years) is unresponsive to a specific psychological
therapy after four to six sessions, although the
evidence for fluoxetine’s effectiveness in this age group
is not established. Note that use of fluoxetine for the
treatment of depression in children under 8 years is
outside of the licensed indications. (Reviewed 2015,
unchanged.) [Based on moderate to low quality RCTs
and the experience and opinion of the 2005 GDG.]
BMJ 2015;350:h824
Board certification for healthcare providers
American Board of Behavioral
Healthcare Practice
Board certification by ABBHP is an indication to both
patients and providers that you are a specialist in
providing behavioral healthcare diagnoses and treatments. Our board certification, the first of its kind,
tells the public and your referral sources that you are a
specialist and partner in the primary care of patients.
See our website to find out if you qualify
http://abbhp.org/
Implications for Educational Classification and
Psychological Diagnoses Using the Wechsler
Adult Intelligence Scale–Fourth Edition With
Canadian Versus American Norms
Building on a recent work of Harrison, Armstrong,
Harrison, Iverson and Lange which suggested that
Wechsler Adult Intelligence Scale–Fourth Edition
(WAIS-IV) scores might systematically overestimate
the severity of intellectual impairments if Canadian
norms are used, the present study examined differences between Canadian and American derived WAISIV scores from 861 postsecondary students attending
school across the province of Ontario, Canada. This
broader data set confirmed a trend whereby individuals’ raw scores systematically produced lower
standardized scores through the use of Canadian as
opposed to American norms. The differences do not
appear to be due to cultural, educational, or population
differences, as participants acted as their own controls.
The ramifications of utilizing the different norms were
examined with regard to psychoeducational assessments and educational placement decisions particularly with respect to the diagnoses of Learning Disability
and Intellectual Disability.
Journal of Psychoeducational Assessment February
26, 2015
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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What others are saying… from Durham University
Voices in people’s heads more complex than previously thought
Voices in people’s heads are far more varied and
complex than previously thought, according to new
research by Durham and Stanford universities,
published in The Lancet Psychiatry today.
“We call into question the presumed auditory
quality of hearing voices and show that there is an
unrecognised complexity in the ‘character’ qualities of
some voices.
One of the largest and most detailed studies to date on
the experience of auditory hallucinations, commonly
referred to as voice hearing, found that the majority
of voice-hearers hear multiple voices with distinct
character-like qualities, with many also experiencing
physical effects on their bodies.
“It is crucial to study mental health and human
experiences such as voice-hearing from a variety of
different perspectives to truly find out what people
are experiencing, not just what we think they must
be experiencing because they have a particular
diagnosis. We hope this approach can help inform the
development of future clinical interventions.”
The study also confirmed that both people with and
without psychiatric diagnoses hear voices.
The findings question some of the current assumptions
about the nature of hearing voices and suggest there is
a greater variation in the way voices are experienced
than is typically recognised.
The researchers say this variation means different
types of therapies could be needed for voice-hearers,
such as tailored Cognitive Behavioural Therapy (CBT)
geared towards distinct voice sub-types or patterns of
voice hearing.
Current common approaches to help with voices
include medication, CBT, voice dialogue techniques
and other forms of therapy and self-help.
Auditory hallucinations are a common feature of many
psychiatric disorders, such as psychosis, schizophrenia
and bipolar disorder, but are also experienced by
people without psychiatric conditions. It is estimated
that between five and 15 per cent of adults will
experience auditory hallucinations during their
lifetimes.
This is one of the first studies to shed light on the
nature of voice-hearing both inside and outside
schizophrenia, across many different mental health
diagnoses.
Lead researcher Dr Angela Woods, from the Centre for
Medical Humanities at Durham University, said: “Our
findings have the potential to overturn mainstream
psychiatric assumptions about the nature of hearing
voices.
The researchers, funded by the Wellcome Trust,
collected answers to open- and close-ended questions
through an on-line questionnaire focused on
description of experiences from 153 respondents. The
majority of respondents had been diagnosed with a
psychiatric condition but 26 had no history of mental
illness. Participants were free to respond in their own
words.
The large majority of respondents described hearing
multiple voices (81 per cent) with characterful qualities
(70 per cent).
Less than half the participants reported hearing
purely auditory voices with 45 per cent reporting
either thought-like or ‘inbetween’ voices with some
thought-like and some acoustic qualities. This finding
challenges the view that hearing voices is always a
perceptual or acoustic phenomenon, and may have
implications for future neuroscientific studies of what
is happening in the brain when people ‘hear’ voices.
66 per cent of people felt bodily sensations while
hearing voices, such as feeling hot or tingling
sensations in their hands and feet. Voices with effects
on the body were more likely to be abusive or violent,
and, in some cases, be linked to experiences of trauma.
While fear, anxiety, depression and stress were often
associated with voices, 31 per cent of participants said
they also felt positive emotions.
Co-author Dr Nev Jones from Stanford University
said: “Our findings regarding the prevalence and
phenomenology of non-acoustic voices are particularly
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
17
Voices in people’s heads more complex
noteworthy. By and large, these voices were not
experienced simply as intrusive or unwanted thoughts,
but rather, like the auditory voices, as distinct ‘entities’
with their own personalities and content. This data
also suggests that we need to think much more
carefully about the distinction between imagined
percepts, such as sound, and perception.”
Case study
Rachel Waddingham is an independent trainer and
consultant with Behind The Label and a trustee
of the National Hearing Voices Network and the
International Society for Psychological and Social
Approaches to Psychosis.
Rachel hears voices, sees visions and has struggled
with overwhelming beliefs.
Rachel explains: “I hear about 13 or so voices. Each of
them is different - some have names, they are different
ages and sound like different people. Some of them are
very angry and violent, others are scared, and others
are mischievous. Sometimes, I hear a child who is very
frightened. When she is frightened I can sometimes
feel pains in my body - burning. If I can help the voice
calm down, by doing some grounding strategies, the
burning pains stop.
Listening to them seems ‘crazy’. Still, in my experience
it can be really useful to be interested in people’s
lived experience of voice-hearing. Every one of us is
different, and being curious about my experiences was
one of the first steps to dealing with them.
“This research is a step forward. If we want to
understand more about voice-hearing, it makes sense
to ask a voice-hearer - and be willing to modify our
perception of what it means to hear voices based on
their answers. For me, the word ‘voices’ isn’t sufficient.
I use it, but it hides the embodied parts of my
experience for which I have few words to describe.
“I would like to live in a world where we are curious
about one another’s experiences and seek to
understand rather than pathologise. Everyone has a
story and the world would be much kinder if we started
to listen to it.”
Durham University Press release 3/10/15
“Since going to a Hearing Voices Group, I have found
ways of making sense of and coping with my voices.
I no longer feel terrorised by them even though some
of them say some very frightening things. I now have
a family of voices and have a better relationship with
them. I can make a choice about how I respond to
them - whether I listen to them, and how I reply.
Some of them are now much more helpful - they can
be a window to my feelings, letting me know about a
problem that I have in my life that I need to address.
“Although in our society, people who hear voices are
often seen as ‘mad’ or ‘crazy’, I do think things are
changing. I find that lots of people are interested
in voice-hearing. Many people have told me about
experiences they have had - either in their childhood,
or as an adult. It’s as if by talking about voices we are
starting to de-stigmatise the experience and opening
the door for others to speak openly too.
“As long as we believe that voices are signs of
pathology and illness, it makes little sense to really
explore a person’s lived experience. Instead we try
to suppress or eliminate the voices as far as possible.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
18
Recent Research on Dementia
Promising Alzheimer’s treatment moves
toward clinical trials
A promising new natural treatment for Alzheimer’s
disease is moving toward clinical trials. This will
be a major step forward as there is nothing on the
market that slows the progression of Alzheimer’s.
Muraleedharan Nair, Michigan State University
natural products chemist, has patented a botanical
compound, withanamides. His spinoff company,
Natural Therapeutics, will begin the trials as soon as
funding is in place.
To date, none of the major pharmaceutical companies
– Merck, Eli Lilly, Bristol-Myers Squibb – have been
able to produce an effective treatment that passed
human clinical trials, Nair said. “This particular
research has focused on Ashwagandha, an herbal
remedy that’s been used in Eastern medicines for
centuries,” he said. “Our compound withanamides may
work to prevent Alzheimer’s disease at the onset, and it
also could prevent its progression.”
While plants cannot be patented, compounds from
them can. MSU holds the patent for withanamides,
and earlier research revealed that the compound,
found in the plants’ seeds, proved to be a powerful
anti-oxidant – double the strength of what’s on today’s
market. The potent compound has shown that it can
protect cells against damaging attacks by a rogue
protein ­– the earliest stage of Alzheimer’s.
Alzheimer’s begins when a specific protein starts
breaking, or cleaving, at the wrong place to produce an
unwanted fragment. This bad fragment, called BAP,
stresses cells’ membranes, sparks plaque formation
and eventually kills the cells. This attack begins in
the frontal lobe, erasing memories and continuing its
unrelenting assault deeper into the brain.
A complicating factor is that the majority of protein
cleaving is a natural, healthy process. Pharmaceutical
companies, however, have focused their efforts on
blocking the tiny faction of bad cleaving of the protein
producing BAP.
“Rather than trying to stop only the malevolent
cleaving, our compound keeps the bad protein from
entering the cell where it does its damage,” said Nair,
who’s in the horticulture department. “Our studies
have shown that withanamides effectively protect the
brain cells by neutralizing the effect of BAP.”
Nair and his collaborators published in Phytotherapy
Research that withanamides protected mouse brain
cells from BAP damage. A recent study, also published
in Phytotherapy Research and using mouse models,
showed that withanamides passed the blood brain
barrier, the filter that controls what chemicals reach
the brain. The results showed that the compound
reached its intended target, passing the last test before
advancing to human testing.
“Dr. Nair discovered his molecule in a food-safe plant,”
said Jim Richter, Natural Therapeutics President. “It’s
also classified as GRAS – generally regarded as safe –
by the FDA. This means that we can bypass many of
the hurdles that slow synthetic molecules that need
testing. By compressing the timeline dramatically,
we’ll be able to save tens of millions of dollars, and if
successful, bring an effective treatment to Alzheimer’s
patients.”
Michigan State University March 10, 2015
Ed: Ashwagandha has been used since ancient times
for a wide variety of conditions. In Ayurvedic, Indian,
and Unani medicine, ashwagandha is described
as “Indian ginseng.” Ashwagandha is also used in
traditional African medicine for a variety of ailments.
More than 200 studies have shown benefits to the
immune system, combating the effects of stress,
improving learning, memory, and reaction time,
reducing anxiety and depression without causing
drowsiness, reducing brain-cell degeneration,
stabilizing blood sugar, lowering cholesterol and
anti-inflammatory benefits. Ashwagandha seems to
be safe when taken by mouth, short-term. Taking
ashwagandha along with medications that decrease
the immune system might decrease the effectiveness of
these medications, such as prednisone, corticosteroids
and others. Do not use ashwagandha if you have an
immune system disease such as multiple sclerosis,
lupus, rheumatoid arthritis, or other autoimmune
diseases.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
19
Dementia research
Drug Restores Brain Function, Memory in
Early Alzheimer’s Disease
BALTIMORE, Md -- March 11, 2015 -- A novel
therapeutic approach for an existing drug reverses a
condition in elderly patients who are at high risk for
dementia due to Alzheimer’s disease, according to a
study published this week in NeuroImage: Clinical.
Levetiracetam, commonly used to treat epilepsy, calms
hyperactivity in the brain of patients with amnestic
mild cognitive impairment (aMCI).
Hippocampal over-activity is well-documented in
patients with aMCI and its occurrence predicts further
cognitive decline and progression to Alzheimer’s
dementia.
“What we’ve shown is that very low doses of the
atypical antiepileptic levetiracetam reduces this overactivity,” said Michela Gallagher, MD, Johns Hopkins
University, Baltimore, Maryland. “At the same time, it
improves memory performance on a task that depends
on the hippocampus.”
The team studied 84 subjects; 17 of them were normal
healthy participants and the rest had symptoms of
aMCI. Everyone was aged older than 55 years. Patients
were randomised to varying doses of levetiracetam or
placebo.
The researchers found that low doses of the drug
improved memory performance and normalised
the over-activity detected by functional magnetic
resonance imaging (fMRI) that measures brain activity
during a memory task.
“What we want to discover now, is whether treatment
over a longer time will prevent further cognitive
decline and delay or stop progression to Alzheimer’s
dementia,” said Dr. Gallagher.
Johns Hopkins University March 11, 2015
Ed: This study holds promise, with a caveat: Contrary
to statements, hippocampal over-activity is NOT welldocumented in patients with aMCI and its occurrence
WEAKLY predicts further cognitive decline and
progression to Alzheimer’s dementia. Still, if I had
dementia, I’d try it.
U.S. Government Accountability Office (GAO)
Report:
HHS Has Initiatives to Reduce Use among
Older Adults in Nursing Homes, but Should
Expand Efforts to Other Settings
Antipsychotic drugs are frequently prescribed to older
adults with dementia. GAO’s analysis found that about
one-third of older adults with dementia who spent
more than 100 days in a nursing home in 2012 were
prescribed an antipsychotic, according to data from
Medicare’s prescription drug program, also known as
Medicare Part D. Among Medicare Part D enrollees
with dementia living outside of a nursing home that
same year, about 14 percent were prescribed an
antipsychotic.
Experts and research identified patient agitation
or delusions, as well as certain setting-specific
characteristics, as factors contributing to the
prescribing of antipsychotics to older adults. For
example, experts GAO spoke with noted that
antipsychotic drugs are often initiated in hospital
settings and carried over when older adults are
admitted to a nursing home. In addition, experts
and research have reported that nursing home staff
levels, particularly low staff levels, lead to higher
antipsychotic drug use.
Agencies within the Department of Health and Human
Services (HHS) have taken several actions to address
antipsychotic drug use by older adults in nursing
homes, as described in HHS’s National Alzheimer’s
Plan.
While the National Alzheimer’s Plan has a goal to
improve dementia care for all individuals regardless
of residence, HHS officials said that efforts to reduce
antipsychotic use have not focused on care settings
outside nursing homes. Stakeholders GAO spoke to
indicated that educational efforts similar to those
provided for nursing homes should be extended
to other settings. Extending educational efforts to
caregivers and providers outside of the nursing home
could help lower the use of antipsychotics among older
adults with dementia living both inside and outside of
nursing homes.
The decision to prescribe an antipsychotic drug to an
older adult with dementia is dependent on a number
of factors, according to experts in the field, and must
take into account the possible benefits of managing
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Dementia research
behavioral symptoms associated with dementia against
potential adverse health risks. In some cases, the
benefits to prescribing the drugs may outweigh the
risks.
HHS has taken important steps to educate and inform
nursing home providers and staff on the need to
reduce unnecessary antipsychotic drug use and ways to
incorporate non-pharmacological practices into their
care to address the behavioral symptoms associated
with dementia. However, similar efforts have not
been directed toward caregivers of older adults living
outside of nursing homes, such as those in assisted
living facilities and private residences.
Targeting this segment of the population is equally
important given that over 1.2 million Medicare Part
D enrollees living outside of nursing homes were
diagnosed with dementia in 2012 and Medicare Part
D pays for antipsychotic drugs prescribed to these
individuals.
While the extent of unnecessary prescribing of
antipsychotic drugs is unknown, older adults with
dementia living outside of nursing homes are also
at risk of the same dangers associated with taking
antipsychotics drugs as residents of nursing homes.
In fact, the National Alzheimer’s Project Act was not
limited to the nursing home setting, but calls upon
HHS to develop and implement an integrated national
plan to address dementia. HHS’s National Alzheimer’s
Plan addresses antipsychotic drug prescribing in
nursing homes only, however, and HHS activities to
reduce such drug use have primarily focused on older
adults residing in nursing homes.
Given that HHS does not specifically target its outreach
and education efforts relating to antipsychotic drug
use to settings other than nursing homes, older adults
living outside of nursing homes, their caregivers, and
their clinicians in these settings may not have access
to the same resources about alternative approaches to
care. By expanding its outreach and educational efforts
to settings outside nursing homes, HHS may be able to
help reduce any unnecessary reliance on antipsychotic
drugs for the treatment of behavioral symptoms
of dementia for all older adults regardless of their
residential setting.
Full report: http://www.gao.gov/assets/670/668221.
pdf
Antipsychotics, Other Psychotropics, and
the Risk of Death in Patients With Dementia
Number Needed to Harm
Antipsychotic medications are associated with
increased mortality in older adults with dementia, yet
their absolute effect on risk relative to no treatment or
an alternative psychotropic is unclear.
To determine the absolute mortality risk increase
and number needed to harm (NNH) (ie, number
of patients who receive treatment that would be
associated with 1 death) of antipsychotic, valproic
acid and its derivatives, and antidepressant use in
patients with dementia relative to either no treatment
or antidepressant treatment, a retrospective casecontrol study was conducted in the Veterans Health
Administration from October 1, 1998, through
September 30, 2009. Participants included 90 786
patients 65 years or older with a diagnosis of dementia.
Final analyses were conducted in August 2014.
Subjects were those who received a new prescription
for an antipsychotic (haloperidol, olanzapine,
quetiapine, and risperidone), valproic acid and its
derivatives, or an antidepressant (46 008 medication
users).
Researchers examined absolute change in mortality
risk and NNH over 180 days of follow-up in medication
users compared with nonmedication users matched
on several risk factors. Among patients in whom a
treatment with medication was initiated, mortality risk
associated with each agent was also compared using
the antidepressant group as the reference, adjusting
for age, sex, years with dementia, presence of delirium,
and other clinical and demographic characteristics.
Secondary analyses compared dose-adjusted absolute
change in mortality risk for olanzapine, quetiapine,
and risperidone.
Compared with respective matched nonusers,
individuals receiving haloperidol had an increased
mortality risk of 3.8% with an NNH (number needed
to kill) of 26; followed by risperidone, 3.7% with
a number needed to kill of 27; olanzapine, 2.5%
with a number needed to kill of 40; and quetiapine,
2.0%with aa number needed to kill of 50. Compared
with antidepressant users, mortality risk ranged
from 12.3% with a number needed to kill of 8 for
haloperidol users to 3.2% with a number needed
to kill of 31 for quetiapine users. As a group, the
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Dementia research
atypical antipsychotics (olanzapine, quetiapine, and
risperidone) showed a dose-response increase in
mortality risk, with 3.5% greater mortality in the highdose subgroup relative to the low-dose group. When
compared directly with quetiapine, dose-adjusted
mortality risk was increased with both risperidone
(1.7%) and olanzapine (1.5%).
The absolute effect of antipsychotics on mortality in
elderly patients with dementia may be higher than
previously reported and increases with dose.
Ed: Yes, you did read that correctly, these figures are
for patients KILLED, not just patients with adverse
effects!
Serum Interleukin (IL)-15 as a Biomarker of
Alzheimer’s Disease
Interleukin (IL-15), a pro-inflammatory cytokine
has been studied as a possible marker of Alzheimer’s
disease (AD); however its exact role in neuroinflammation or the pathogenesis AD is not well
understood yet. A Multiple Indicators Multiple
Causes (MIMIC) approach was used to examine the
relationship between serum IL-15 levels and AD in a
well characterized AD cohort, the Texas Alzheimer’s
Research and Care Consortium (TARCC). Instead of
categorical diagnoses, we used two latent construct
d (for dementia) and g’ (for cognitive impairments
not contributing to functional impairments) in our
analysis. The results showed that the serum IL-15
level has significant effects on cognition, exclusively
mediated by latent construct d and g’. Contrasting
directions of association lead us to speculate that
IL-15’s effects in AD are mediated through functional
networks as d scores have been previously found to be
specifically related to default mode network (DMN).
Our finding warrants the need for further research to
determine the changes in structural and functional
networks corresponding to serum based biomarkers
levels.
PLoS ONE 10(2): e0117282.
Ed: Interleukin 15 (IL-15) is a cytokine secreted by
mononuclear phagocytes (and some other cells)
following infection by virus(es). This cytokine induces
cell proliferation of natural killer cells; cells of the
innate immune system whose principal role is to kill
virally infected cells.
Anticholinergic Medications and Risk of
Community-Acquired Pneumonia in Elderly
Adults: A Population-Based Case–Control
Study
To determine whether use of anticholinergics
is associated with risk of community-acquired
pneumonia in older adults, data from a nested
case–control study of community-dwelling
immunocompetent adults aged 65 to 94 were analyzed.
Pneumonia cases (n = 1,039) were ascertained and
validated using chart review. Controls (n = 2,022) were
matched 2:1 to cases according to age, sex, and year.
Anticholinergic medication exposure was ascertained
using prescription data; acute use was defined as one
or more prescription fills 90 days or less before the
index date (date of pneumonia diagnosis), past use
was defined as one or more prescription fills within
the prior year but none within 90 days, and chronic
use was defined as three or more prescription fills
within the prior year. The reference group was those
with no fills in the prior year. Conditional logistic
regression was used to analyze the association between
anticholinergic use and pneumonia, adjusted for
comorbidities.
Acute use of anticholinergics was observed in 59% of
cases and 35% of controls (adjusted odds ratio (aOR)
= 2.55, 95% confidence interval (CI) = 2.08–3.13)
and past use in 17% of cases and 23% of controls
(aOR = 1.19, 95% CI = 0.92–1.53). Chronic use of
anticholinergics was observed in 53% of cases and
36% of controls (aOR 2.07, 95% CI = 1.68–2.54).
Results were not different for high- and low-potency
anticholinergic medications.
Conclusions: In older adults, anticholinergic
medication use is associated with pneumonia risk,
adding to substantial evidence suggesting that these
medications are high risk.
Journal of the American Geriatrics Society March 2,
2015
Ed: Anticholinergics include Wellbutrin®,
Zyban®, Cogentin®, Advil PM®, Sominex®,
dextromethorphan, Spiriva®, Ditropan®, and a host
of OTC cold and cough remedies.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
22
Dementia research
Donepezil can improve daily activities and
promote rehabilitation for severe Alzheimer’s
patients in long-term care health facilities.
0.011, respectively). Most of them were smoothly
introduced to rehabilitation, and the proportion of
accidental falls decreased. Psychosocial intervention
in N1 without the drug only improved the total score
(Wilcoxon, p =0.046).
Cholinesterase inhibitors can delay the progression
of Alzheimer’s disease (AD). Several clinical trials of
the drug in moderate to severe AD have consistently
reported clinically positive effects. A combining effect
with psychosocial intervention was reported in mild to
moderate AD patients.
ConclusionsA combined therapeutic approach of
donepezil and psychosocial intervention can have
a positive effect, even for severe patients through
the introduction of rehabilitation and decreasing
accidental falls.
Since a therapeutic approach or rehabilitation
combined with cholinesterase inhibitors for severe
AD patients remains controversial, we performed a
prospective intervention for patients in Long-Term
Care Health Facilities (LTCHF) Two LTCHFs (N1,
N2) were enrolled. N1 is a 126-bed facility that does
not treat with donepezil but rather with psychosocial
intervention (reality orientation and reminiscence).
N2 is a 150-bed facility with a 50-bed special dementia
unit, in which the physician can prescribe donepezil.
On top of the similar psychosocial intervention,
rehabilitation is performed in N2.
BMC Neurol. 2014 Dec 17;14(1):243. [Epub ahead of
print]
Ed: Medscape reported some of the details of this
study: “The effects of donepezil on MMSE were not
apparent unless the psychosocial intervention was
added.:”
“Rehabilitation for walking was also performed by a
physical therapist in N2.” Since this was not broken
out, the improvements in fall risk and other markers in
N2 over N1 may be wholly due to the physical therapy
and stimulation.
Thirty-two severe AD patients (MMSE <6) in N1
and N2 (16 vs. 16) were compared for the effect of
donepezil (10 mg/d for 3 months) with or without
psychosocial intervention (n =8 vs. 8 for each facility).
The Vitality Index was used to assess daily activities
and the introduction of rehabilitation. The response
ratio (MMSE 3+) of donepezil was 37.5% in N2.
The combination of donepezil with the psychosocial
intervention improved the Vitality Index total score,
and Communication, Eating, and Rehabilitation
subscores (Wilcoxon, p =0.016, 0.038, 0.023, and
A MERICAN B OARD
OF
“MMSE score is not an appropriate measure for
patients with severe AD.” An MMSE score of 0-5 is
VERY low.
The drug intervention benefit was minimal to nonexistent. Aricept 10 mg costs about $398 per month.
Common reactions (greater than 10%) include nausea,
headache, diarrhea, pain, insomnia, dizziness, muscle
cramps, fatigue, vomiting, anorexia, weight loss,
depression, abnormal dreams, syncope, arthritis,
somnolence, urinary frequency and dyspepsia.
M EDICAL P SYCHOLOGY
A P SYCHOLOGY S PECIALTY E NCOMPASSING
B EHAVIORAL H EALTHCARE ,
P SYCHOPHARMACOLOGY , AND M ENTAL
H EALTH T REATMENT IN M ULTI DISCIPLINARY AND TEAM T REATMENT
A PPROACHES AND H EALTHCARE F ACILITIES .
©
S EE THE A RCHIVES OF M EDICAL P SYCHOLOGY AT OUR WEB S ITE
See: www.AMPhome.org for a description of specialty standards and the application process
Four opportunities that involve different designations in Medical Psychology;
Medical Psychologist (American Board of Medical Psychology Diplomate).
Fellow of the Academy of Medical Psychology.
Member of the Academy of Medical Psychology, or Student Member of the Academy of Medical Psychology, is someone interested in the area, but not qualified for diplomate status at this time.
Qualifications for each of these AMP Membership categories are described on our website at
www.AMPhome.org.
©
©
Manuscripts may be submitted to:
Dr. Jack Wiggins, Editor, at
[email protected]
Join the Most Sought After Specialists in the Emerging Era of
Integrated Care and Multi-disciplinary Facilities Staffing
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
23
FDA News
FDA Safety label Changes
Exelon capsules and oral solution
WARNINGS AND PRECAUTIONS
Allergic Dermatitis: here have been isolated postmarketing reports of patients experiencing disseminated
allergic dermatitis when administered rivastigmine
irrespective of the route of administration (oral or
transdermal). Treatment should be discontinued if
disseminated allergic dermatitis occurs. Patients and
caregivers should be instructed accordingly.
ADVERSE REACTIONS
Postmarketing Experience: Skin and Appendages: disseminated allergic dermatitis.
DRUG INTERACTIONS: Metoclopramide- Due to the
risk of additive extrapyramidal adverse reactions, the
concomitant use of metoclopramide and Exelon is not
recommendedd.
Cholinomimetic and Anticholinergic MedicationsExelon may increase the cholinergic effects of other
cholinomimetic medications and may also interfere
with the activity of anticholinergic medications (e.g.,
oxybutynin, tolterodine). Concomitant use of Exelon
with medications having these pharmacologic effects is
not recommended unless deemed clinically necessary.
Beta-blockers- Additive bradycardic effects resulting
in syncope may occur when Exelon is used concomitantly with beta-blockers, especially cardioselective
beta-blockers (including atenolol). Concomitant use of
Exelon with beta-blockers is not recommended.
Postmarketing Experience
Hepatobiliary Disorders: Hepatitis.
Psychiatric Disorders: Aggression
Skin and Appendages: disseminated cutaneous hypersensitivity reactions
Namenda (Razadyne) (galantamine hydrobromide) Tablets, Oral Solution, and Razadyne ER
(galantamine HBr) Extended-Release Capsules
WARNINGS AND PRECAUTIONS
Serious Skin Reactions: Serious skin reactions (Stevens-Johnson syndrome and acute generalized exanthematous pustulosis) have been reported in patients
receiving Razadyne ER and Razadyne. Inform patients
and caregivers that the use of Razadyne ER or Raza-
dyne should be discontinued at the first appearance of
a skin rash, unless the rash is clearly not drug-related.
If signs or symptoms suggest a serious skin reaction,
use of this drug should not be resumed and alternative
therapy should be considered.
Postmarketing Experience:
Gastrointestinal System Disorders: upper and lower
GI bleeding, stomach discomfort, abdominal discomfort
Nervous System Disorders: lethargy, dysgeusia,
hypersomnia
Eye Disorders: vision blurred
Immune System Disorders: Hypersensitivity
Hepatobiliary Disorders: elevated liver enzymes,
hepatitis
FDA Okays Saphris for Pediatric Bipolar Disorder
The US Food and Drug Administration (FDA) has
approved another atypical antipsychotic for the treatment of pediatric patients with bipolar I disorder.
According to a release issued by the drug’s manufacturer, Actavis, asenapine (Saphris) received approval
as monotherapy for the acute treatment of manic or
mixed episodes associated with bipolar I disorder in
pediatric patients aged 10 to 17 years.
The company notes that the drug is the only atypical
antipsychotic treatment that offers a sublingual formulation.
According to the company, the FDA approval is based
on the results of a 3-week monotherapy trial in 403
pediatric patients (aged 10 to 17 years), of whom 302
patients received Saphris twice daily in doses of either 2.5 mg, 5 mg, or 10 mg.The drug’s risks include
death, transient ischemic attacks, and stroke in elderly
patients with dementia-related psychosis, and so it is
not recommended for use in this patient population.
Other risks include severe liver impairment, serious
allergic reaction, neuroleptic malignant syndrome,
tardive dyskinesia, and metabolic changes that can
increase cardiovascular risk, including hyperglycemia,
dyslipidemia, and weight gain.
Saphris is approved for schizophrenia and ACUTE
treatment of manic or mixed episodes of Bipolar 1
disorder.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Science Notes- Drugs
Efficacy and Acceptability of Pharmacological
Treatments for Depressive Disorders in Primary Care: Systematic Review and Network
Meta-Analysis
The purpose of this study was to investigate whether
antidepressants are more effective than placebo in
the primary care setting, and whether there are differences between substance classes regarding efficacy
and acceptability. We conducted literature searches
in MEDLINE, Embase, Cochrane Central Register of
Controlled Trials (CENTRAL), and PsycINFO up to
December 2013. Randomized trials in depressed adults
treated by primary care physicians were included in
the review. We performed both conventional pairwise
meta-analysis and network meta-analysis combining
direct and indirect evidence. Main outcome measures
were response and study discontinuation due to adverse effects.
A total of 66 studies with 15,161 patients met the inclusion criteria. In network meta-analysis, tricyclic and
tetracyclic antidepressants (TCAs), selective serotonin
reuptake inhibitors (SSRIs), a serotonin-noradrenaline
reuptake inhibitor (SNRI; venlafaxine), a low-dose
serotonin antagonist and reuptake inhibitor (SARI;
trazodone) and hypericum extracts were found to be
significantly superior to placebo, with estimated odds
ratios between 1.69 and 2.03. There were no statistically significant differences between these drug classes.
Reversible inhibitors of monoaminoxidase A (rMAOAs) and hypericum extracts were associated with
significantly fewer dropouts because of adverse effects
compared with TCAs, SSRIs, the SNRI, a noradrenaline reuptake inhibitor (NRI), and noradrenergic and
specific serotonergic antidepressant agents (NaSSAs).
CONCLUSIONS Compared with other drugs, TCAs
and SSRIs have the most solid evidence base for being
effective in the primary care setting, but the effect size
compared with placebo is relatively small. Further
agents (hypericum, rMAO-As, SNRI, NRI, NaSSAs,
SARI) showed some positive results, but limitations of
the currently available evidence makes a clear recommendation on their place in clinical practice difficult.
Ann Fam Med January/February 2015
Ed: According to this study, all of the common
“anti”depressants were no more effective than St.
John’s Wort, and the natural approach had significantly lower dropouts and adverse effects. Despite this, the
abstract writer did find “a clear recommendation on
their place in clinical practice difficult” given the clear
advantage of St. John’s Wort. Still, relieving depression just as well as “anti”depressants is not much of a
recommendation, see below.
SSRI No Better Than Placebo in Depressed
CHF Patients
In what its investigators call “the first larger-scale”
randomized controlled trial to assess long-term efficacy and safety of a selective serotonin reuptake
inhibitor (SSRI) in patients with chronic heart failure
(CHF), there were no significant differences in clinical outcomes between escitalopram and placebo. The
Mortality, Morbidity and Mood in Depressed Heart
Failure Patients (MOOD-HF) study of more than 300
patients showed that 60% of those who received the
SSRI escitalopram and 61% of those receiving matching placebo had an unplanned hospitalization for any
reason or all-cause death over the following 24 months
(the primary outcome). Although patients receiving
the SSRI did have significant decreases in depression
symptom scores after 12 weeks of treatment, the reduction was similar in the placebo group. The findings
were presented last week at a featured clinical-research
session at the American College of Cardiology (ACC)
2015 Scientific Sessions.
“MOOD-HF does not provide a rationale for the use
of escitalopram in these patients,” said lead investigator Dr Christiane E Angermann (University of Würzburg Comprehensive Heart Failure Center, Germany)
during her presentation. It does suggest, however,
“that optimal heart-failure management resulting in
improved signs and symptoms might possibly also be
a means to ameliorate comorbid depression,” added
Angermann.
The investigators enrolled 372 adult patients (mean
age 62 years) with stable symptomatic CHF (LV ejection fraction <45%) and clinically diagnosed depression, based on scores of at least 12 on the Patient
Health Questionnaire 9 (PHQ-9; mean baseline score
15) and later confirmed by a psychiatrist using the
Structured Clinical Interview (SCID). Within 2 weeks
of undergoing the SCID, all were randomly assigned to
receive, along with heart-failure pharmacotherapy, up
to 20 mg of escitalopram once daily (n=185, 76% men;
mean daily dose at 12 weeks 13.7 mg) or matching
placebo (n=187, 75% men). None of the participants
had taken an SSRI or other antidepressant previously
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Science Notes- Drugs
or had a history of suicide or severe depressive episodes. Follow-ups were scheduled for 24 months after
baseline (actual mean participation was 18.4 months
for the escitalopram group vs 18.8 months for the placebo group). The primary end point was a composite
of unplanned hospitalizations for any cause or deaths;
the major secondary end point was reduced score on
the Montgomery-Åsberg Depression Rating Scale
(MADRS). Prespecified secondary outcomes included
individual components of the primary end point, CV
deaths, and HF-related hospitalizations, and safety
issues.
Results showed no significant differences between the
treatment groups for the primary outcome measure,
with events happening to 116 of those receiving the
study drug vs 119 of those receiving placebo (hazard
ratio [HR] 0.99). There were no differences for the
individual components of the primary end point. Depression score decreases at 12 weeks on the MADRS
were significant but similar between groups (change
from 20.3 to 11.1 and from 21.4 to 12.6, respectively;
both, P<0.001). In addition, 46% of those receiving
the active medication vs 48% of those receiving placebo had a treatment-related adverse event not including hospitalization and death; 86% vs 80% of these
patients reported that the event was severe.
Overall, “escitalopram neither improved the
composite primary outcome nor depression in
this population compared with placebo,” said
Angermann.
Medscape conference news, march 25, 2015, reporting
on American College of Cardiology (ACC) 2015 Scientific Sessions
Metabolic Monitoring for Youths Initiating Use
of Second-Generation Antipsychotics, 2003–
2011
In 2004, the American Diabetes Association (ADA) released treatment guidelines recommending metabolic
screening for children and adolescents before and after
initiation of second-generation antipsychotics. Prior
studies showed that the guidelines coincided with a
small increase in glucose testing of children and adults
but had limited follow-up. This study sought to evaluate changes in metabolic screening of children initiating second-generation antipsychotics around the time
of the 2004 guidelines and in the following eight years.
Methods:
Study patients (N=52,407) were identified in a large
nationwide commercial insurance claims database
for the period January 1, 2003, through December 31,
2011. The study population was a cohort of nondiabetic
new users of second-generation antipsychotics who
were ages 5–18. Glucose and HbA1c tests completed
before and after second-generation antipsychotic
initiation were identified with Current Procedural
Terminology–4 codes. Metabolic screening was also
examined by second-generation antipsychotic agent
prescribed and psychiatric diagnosis.
Results: The proportion of patients receiving a glucose test preinitiation increased from 17.9% in 2003
to 18.9% in 2004, and testing postinitiation increased
from 14.7% to 16.6% in the same period. The slight
increase in glucose testing was not sustained; the proportion tested dropped in the following years before
rising again in 2008. Glucose screening was most
common for patients taking aripiprazole. Patients with
a diagnosis of hyperkinetic disorder were less likely to
be tested. HbA1c testing was less frequent but had a
similar usage pattern.
Conclusions: The small improvement in metabolic
screening immediately after the 2004 ADA guidelines
were issued was not sustained. Overall, metabolic
screening rates remained suboptimal throughout the
study period.
Psychiatric Services http://dx.doi.org/10.1176/appi.
ps.201400222
The Neuroanatomical Basis of Panic Disorder
and Social Phobia in Schizophrenia: A Voxel
Based Morphometric Study
Individualized Homeopathic Treatment and Fluoxetine for Moderate to Severe Depression in Peri- and
Postmenopausal Women (HOMDEP-MENOP Study):
A Randomized, Double-Dummy, Double-Blind, Placebo-Controlled Trial
Perimenopausal period refers to the interval when
women’s menstrual cycles become irregular and is
characterized by an increased risk of depression. Use
of homeopathy to treat depression is widespread but
there is a lack of clinical trials about its efficacy in depression in peri- and postmenopausal women. The aim
of this study was to assess efficacy and safety of individualized homeopathic treatment versus placebo and
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Science Notes- Drugs
fluoxetine versus placebo in peri- and postmenopausal
women with moderate to severe depression.
A randomized, placebo-controlled, double-blind,
double-dummy, superiority, three-arm trial with a 6
week follow-up study was conducted. The study was
performed in a public research hospital in Mexico City
in the outpatient service of homeopathy. One hundred thirty-three peri- and postmenopausal women
diagnosed with major depression according to DSMIV (moderate to severe intensity) were included. The
outcomes were: change in the mean total score among
groups on the 17-item Hamilton Rating Scale for Depression, Beck Depression Inventory and Greene Scale,
after 6 weeks of treatment, response and remission
rates, and safety. Efficacy data were analyzed in the
intention-to-treat population (ANOVA with Bonferroni
post-hoc test).
After a 6-week treatment, homeopathic group was
more effective than placebo by 5 points in Hamilton Scale. Response rate was 54.5% and remission
rate, 15.9%. There was a significant difference among
groups in response rate definition only, but not in
remission rate. Fluoxetine-placebo difference was 3.2
points. No differences were observed among groups in
the Beck Depression Inventory. Homeopathic group
was superior to placebo in Greene Climacteric Scale
(8.6 points). Fluoxetine was not different from placebo
in Greene Climacteric Scale.
Conclusions: Homeopathy and fluoxetine are effective and safe antidepressants for climacteric women.
Homeopathy and fluoxetine were significantly different
from placebo in response definition only. Homeopathy,
but not fluoxetine, improves menopausal symptoms
scored by Greene Climacteric Scale.
PLoS ONE 10(3): e0118440.
Ed: Homeopathy is a treatment modality based on
the belief that taking an extensively diluted solution of
an herb or other substance known to cause symptoms
similar to those that you wish to treat will result in
the body mounting a defense and subsequently curing
itself of the target symptom. A typical homeopathic
remedy for schizophrenia symptoms would be Anacardium Orientale, an extract of the Malacca nut tree,
diluted with water to 30C, or 10-60 . Most, but not all
scientists believe homeopathy cannot possibly work,
and consider such treatments to be equivalent to placebos.
Homeopathy is NOT herbal medicine. Herbal medicine uses normal concentrations (usually about 6:1)
of natural substances to treat symptoms and causes of
symptoms, for a total “raw herb” dose of typically 2400
mg/day. This treatment modality’s effectiveness is
substantiated by the adoption and concentration, and
later synthesis of natural compounds to develop the
vast majority of pharmaceuticals now on the market..
Whether you consider homeopathy equigvalent to
placebo or not, this study found it MORE effective
than Prozac for panic and social anxiety in this study,
without adverse effects.such as worsening depression,
slowing recovery and destroying sex drive.
Prenatal maternal depression alters amygdala
functional connectivity in 6-month-old infants
Prenatal maternal depression is associated with alterations in the neonatal amygdala microstructure, shedding light on the timing for the influence of prenatal
maternal depression on the brain structure of the
offspring.
This study aimed to examine the association between
prenatal maternal depressive symptomatology and
infant amygdala functional connectivity and to thus
establish the neural functional basis for the transgenerational transmission of vulnerability for affective
disorders during prenatal development.
Twenty-four infants were included in this study with
both structural magnetic resonance imaging (MRI)
and resting-state functional MRI (fMRI) at 6 months
of age. Maternal depression was assessed at 26 weeks
of gestation and 3 months after delivery using the Edinburgh Postnatal Depression Scale. Linear regression
was used to identify the amygdala functional networks
and to examine the associations between prenatal maternal depressive symptoms and amygdala functional
connectivity.
Our results showed that at 6 months of age, the amygdala is functionally connected to widespread brain
regions, forming the emotional regulation, sensory
and perceptual, and emotional memory networks.
After controlling for postnatal maternal depressive
symptoms, infants born to mothers with higher prenatal maternal depressive symptoms showed greater
functional connectivity of the amygdala with the left
temporal cortex and insula, as well as the bilateral
anterior cingulate, medial orbitofrontal and ventrome-
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Science Notes- Drugs
dial prefrontal cortices, which are largely consistent
with patterns of connectivity observed in adolescents
and adults with major depressive disorder. Our study
provides novel evidence that prenatal maternal depressive symptomatology alters the amygdala’s functional
connectivity in early postnatal life, which reveals that
the neuroimaging correlates of the familial transmission of phenotypes associated with maternal mood are
apparent in infants at 6 months of age.
Translational Psychiatry (2015) 5, e508
Ed: A review of the study shows that the authors
controlled for household income, prenatal alcohol
exposure and smoking. They did NOT control for
“anti”depressant use. The ability of some psychotropic chemicals to cause physical brain abnormalities has
been well documented.
Child/Adolescent Anxiety Multimodal Study:
Evaluating Safety
To evaluate the frequency of adverse events (AEs)
across 4 treatment conditions in the Child/Adolescent
Anxiety Multimodal Study (CAMS), and to compare
the frequency of AEs between children and adolescents.
Participants ages 7 to 17 years (mean = 10.7 years)
meeting the DSM-IV criteria for 1 or more of the following disorders: separation anxiety disorder, generalized anxiety disorder, or social phobia were randomized (2:2:2:1) to cognitive-behavioral therapy (CBT,
n = 139), sertraline (SRT, n = 133), a combination of
both (COMB, n = 140), or pill placebo (PBO, n = 76).
Data on AEs were collected via a standardized inquiry
method plus a self-report Physical Symptom Checklist
(PSC).
There were no differences between the double-blinded
conditions (SRT versus PBO) for total physical and
psychiatric AEs or any individual physical or psychiatric AEs. The rates of total physical AEs were greater
in the SRT-alone treatment condition when compared
to CBT (p < .01) and COMB (p < .01). Moreover, those
who received SRT alone reported higher rates of several physical AEs when compared to COMB and CBT.
The rate of total psychiatric AEs was higher in children
(≤12 years) across all arms (31.7% versus 23.1%, p <
.05). Total PSC scores decreased over time, with no
significant differences between treatment groups.
of selective serotonin reuptake inhibitor (SSRI) treatment for anxiety disorders even after adjusting for
the number of reporting opportunities, leading to no
differences in overall rates of AEs. Few differences occurred on specific items. Additional monitoring of psychiatric AEs is recommended in children (≤12 years).
JAACAP March 15 v. 54 I.3 Pg 180-190
Ed: Not surprisingly, both children and adolescents
suffered physically from use of “anti”depressants compared to CBT.
Cause or Effect? Selective Serotonin Reuptake
Inhibitors and Falls in Older Adults: A Systematic Review
A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based
on fall risk. The application of these recommendations,
not only to frail nursing home residents, but also to all
older adults, may lead to changes in health policy or
clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs
and falls in older adults was conducted to examine the
evidence for causation. Twenty-six studies met the
inclusion criteria. The majority of studies were observational and suggest an association between SSRIs
and falls. The direction of the relationship – causation
or effect- cannot be discerned from this type of study.
Standardized techniques for determining likely causation were then used to see if there was support for the
hypothesis that SSRI’s lead to falls. This analysis did
not suggest causation was likely. There is no Level 1
evidence that SSRIs cause falls. Therefore, changes in
the current treatment guidelines or policies on the use
of SSRIs in older adults based on fall risk may not be
justified at this time given the lack of an established
evidence base. Given its significance to public health,
well-designed experimental studies are required to address this question definitively.
AJGeriatricPsychiatry November 25, 2014
Ed: This certainly sounds like the “tobacco doesn’t
cause cancer” argument.
Conclusion: The results support the tolerability/safety
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Peroxisome Proliferator-Activated Receptor
γ Controls Ingestive Behavior, Agouti-Related
Protein, and Neuropeptide Y mRNA in the Arcuate Hypothalamus
Peroxisome proliferator-activated receptor γ (PPARγ)
is clinically targeted for type II diabetes treatment;
however, rosiglitazone (ROSI), a PPARγ agonist, increases food intake and body/fat mass as side-effects.
We tested this role in Siberian hamsters, a model of
human energy balance, and C57BL/6 mice. We tested
the following: (1) how ROSI and/or GW966 2 (2-chloro-5-nitro-N-phenylbenzamide; PPARγ antagonist)
injected intraperitoneally or into the third ventricle
(3V) affected Siberian hamster feeding behaviors; (2)
whether food deprivation (FD) co-increases agouti-related protein (AgRP) and PPARγ mRNA expression in
Siberian hamsters and mice; (3) whether intraperitoneally administered ROSI increases AgRP and NPY in
ad libitum-fed animals; (4) whether intraperitoneally
administered PPARγ antagonism blocks FD-induced
increases in AgRP and NPY; and finally, (5) whether
intraperitoneally administered PPARγ modulation affects plasma ghrelin.
Third ventricular and intraperitoneally administered
ROSI increased food hoarding and intake for 7 d, an
effect attenuated by 3V GW9662, and also prevented
(intraperitoneal) FD-induced feeding. FD hamsters
and mice increased AgRP within the arcuate hypothalamic nucleus with concomitant increases in PPARγ
exclusively within AgRP/NPY neurons. ROSI increased
AgRP and NPY similarly to FD, and GW9662 prevented FD-induced increases in AgRP and NPY in both
species. Neither ROSI nor GW9662 affected plasma
ghrelin.
Thus, we demonstrated that PPARγ activation is sufficient to trigger food hoarding/intake, increase AgRP/
NPY, and possibly is necessary for FD-induced increases in feeding and AgRP/NPY. These findings provide
initial evidence that FD-induced increases in AgRP/
NPY may be a direct PPARγ-dependent process that
controls ingestive behaviors.
The Journal of Neuroscience, 18 March 2015
Ed: Thiazolidinediones include the diabetic drugs
rosiglitazone (Avandia), pioglitazone (Actos), lobeglitazone (Duvie), and troglitazone (Rezulin), all widely
advertised and prescribed. These may be the perfect
profit vehicles- they insure their own continued use!
Science Notes- Alternative Approaches
Associations between vitamin D levels and
depressive symptoms in healthy young adult
women
There have been few studies of whether vitamin D insufficiency is linked with depression in healthy young
women despite women‫׳‬s high rates of both problems.
Female undergraduates (n=185) living in the Pacific
Northwest during fall, winter, and spring academic
terms completed the Center for Epidemiologic Studies
Depression (CES-D) scale weekly for 4 weeks (W1–
W5). We measured serum levels of vitamin D3 and
C (ascorbate; as a control variable) in blood samples
collected at W1 and W5. Vitamin D insufficiency (<30
ng/mL) was common at W1 (42%) and W5 (46%),
and rates of clinically significant depressive symptoms (CES-D≥16) were 34–42% at W1–W5. Lower W1
vitamin D3 predicted clinically significant depressive
symptoms across W1–W5 (β=−0.20, p<0.05), controlling for season, BMI, race/ethnicity, diet, exercise,
and time outside. There was some evidence that lower
levels of depressive symptoms in Fall participants (vs.
Winter and Spring) were explained by their higher
levels of vitamin D3. W1 depressive symptoms did not
predict change in vitamin D3 levels from W1 to W5.
Conclusion: Findings are consistent with a temporal
association between low levels of vitamin D and clinically meaningful depressive symptoms. The preventive
value of supplementation should be tested further.
Psychiatry Research 5 March 2015
Irritable Brain Caused by Irritable Bowel? A
Nationwide Analysis for Irritable Bowel Syndrome and Risk of Bipolar Disorder
We explored the association between IBS and the development of bipolar disorder, and the risk factors for
bipolar disorders in patients with IBS.
We identified patients who were newly diagnosed with
IBS between 2000 and 2010 in the Taiwan National
Health Insurance Research Database. We also identified a comparison matched cohort without IBS. The occurrence of new-onset bipolar disorder was evaluated
in both cohorts.
The IBS cohort consisted of 30,796 patients and the
comparison cohort consisted of 30,796 matched patients without IBS. The incidence of bipolar disorder
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Science Notes- Alternative Approaches
(incidence rate ratio, 2.63, 95% confidence interval
(CI) 2.10–3.31, P < .001) was higher in the IBS patients
than in the matched cohort. Multivariate matched
regression models indicated that autoimmune diseases
(HR 1.52, 95% CI 1.07–2.17, P = .020), and asthma
(HR 1.45, 95% CI 1.08–1.95, P = .013) were independent risk factors for the development of bipolar disorder in the IBS patients.
Conclusion: IBS may increase the risk of developing
subsequent bipolar disorder. Additional prospective
studies are required to confirm these findings.
PLoS ONE.0118209 March 13, 2015
Ed: It is difficult to deny the physical contributors of
“mental” disorders; IBS is an autoimmune inflammatory disorder closely linked to food allergies.
Zinc deficiency linked to immune system response, particularly in older adults
Zinc, an important mineral in human health, appears
to affect how the immune system responds to stimulation, especially inflammation, new research from
Oregon State University shows.
Zinc deficiency could play a role in chronic diseases
such as cardiovascular disease, cancer and diabetes
that involve inflammation. Such diseases often show
up in older adults, who are more at risk for zinc deficiency.
“When you take away zinc, the cells that control inflammation appear to activate and respond differently;
this causes the cells to promote more inflammation,”
said Emily Ho, a professor and director of the Moore
Family Center for Whole Grain Foods, Nutrition and
Preventive Health in the OSU College of Public Health
and Human Sciences, and lead author of the study.
Zinc is an essential micronutrient required for many
biological processes, including growth and development, neurological function and immunity. It is naturally found in protein-rich foods such as meat and
shellfish, with oysters among the highest in zinc content.
Approximately 12 percent of people in the U.S. do not
consume enough zinc in their diets. Of those 65 and
older, closer to 40 percent do not consume enough
zinc, Ho said. Older adults tend to eat fewer zinc-rich
foods and their bodies do not appear to use or absorb
zinc as well, making them highly susceptible to zinc
deficiency.
“It’s a double-whammy for older individuals,” said
Ho, who also is a principal investigator with the Linus
Pauling Institute.
In the study, researchers set out to better understand
the relationship between zinc deficiency and inflammation. They conducted experiments that indicated
zinc deficiency induced an increase in inflammatory
response in cells. The researchers were able to show,
for the first time, that reducing zinc caused improper
immune cell activation and dysregulation of a cytokine
IL-6, a protein that affects inflammation in the cell, Ho
said.
Researchers also compared zinc levels in living mice,
young and old. The older mice had low zinc levels that
corresponded with increased chronic inflammation
and decreased IL-6 methylation, which is an epigenetic
mechanism that cells use to control gene expression.
Decreased IL-6 methylation also was found in human
immune cells from elderly people, Ho said.
Together, the studies suggest a potential link between
zinc deficiency and increased inflammation that can
occur with age, she said.
The findings were published recently in the journal
Molecular Nutrition & Food Research. Co-authors are
Carmen P. Wong and Nicole A. Rinaldi of the College
of Public Health and Human Sciences. The research
was supported by the Oregon Agricultural Experiment
Station, Bayer Consumer Care AG of Switzerland, and
OSU.
Understanding the role of zinc in the body is important to determining whether dietary guidelines for zinc
need to be adjusted. The recommended daily intake of
zinc for adults is 8 milligrams for women and 11 milligrams for men, regardless of age. The guidelines may
need to be adjusted for older adults to ensure they are
getting enough zinc, Ho said.
There is no good clinical biomarker test to determine
if people are getting enough zinc, so identifying zinc
deficiency can be difficult. In addition, the body does
not have much ability to store zinc, so regular intake is
important, Ho said. Getting too much zinc can cause
other problems, including interfering with other minerals. The current upper limit for zinc is 40 milligrams
per day.
“We think zinc deficiency is probably a bigger problem
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Science Notes- Alternative Approaches
than most people realize,” she said. “Preventing that
deficiency is important.”
OSU College of Public Health and Human Sciences
03/23/2015
Ed: According to the USDA, 20% for those between
51-70, and up to 36% of those over 70 do not get
enough zinc from their diet. Zinc is absorbed using the same pathway as iron, and each will interfere
with the other. Zinc is a key ingredient in superoxide
dysmutase, our brain’s natural defense against free
radical damage, and possibly dementia. We were more
assured of adequate zinc when our house piping was
zinc coated (galvanized), but the switch to copper (and
plastic) since the 1960’s has changed our nutritional
balance. I recommend every adult take 50 mg of zinc
every other day, to maintain adequate levels.
Sleep deprivation is common in critically ill
patients in the intensive care unit (ICU).
Noise and light in the ICU and the reduction in
plasma melatonin play the essential roles. The aim
of this study was to determine the effect of simulated
ICU noise and light on nocturnal sleep quality, and
compare the effectiveness of melatonin and earplugs
and eye masks on sleep quality in these conditions in
healthy subjects.
This study was conducted in two parts. In part one, 40
healthy subjects slept under baseline night and simulated ICU noise and light (NL) by a cross-over design.
In part two, 40 subjects were randomly assigned to
four groups: NL, NL plus placebo (NLP), NL plus
use of earplugs and eye masks (NLEE) and NL plus
melatonin (NLM). 1 mg of oral melatonin or placebo
was administered at 21:00 on four consecutive days
in NLM and NLP. Earplugs and eye masks were made
available in NLEE. The objective sleep quality was
measured by polysomnography. Serum was analyzed
for melatonin levels. Subjects rated their perceived
sleep quality and anxiety levels.
Subjects had shorter total sleep time (TST) and rapid
eye movement (REM) sleep, longer sleep onset latency,
more light sleep and awakening, poorer subjective
sleep quality, higher anxiety level and lower serum
melatonin level in NL night (P <0.05). NLEE had less
awakenings and shorter sleep onset latency (P <0.05).
NLM had longer TST and REM and shorter sleep onset
latency (P <0.05). Compared with NLEE, NLM had
fewer awakenings (P = 0.004). Both NLM and NLEE
improved perceived sleep quality and anxiety level
(P = 0.000), and NLM showed better than NLEE in
perceived sleep quality (P = 0.01). Compared to baseline night, the serum melatonin levels were lower in
NL night at every time point, and the average maximal
serum melatonin concentration in NLM group was
significantly greater than other groups (P <0.001).
Conclusions: Compared with earplugs and eye masks,
melatonin improves sleep quality and serum melatonin
levels better in healthy subjects exposed to simulated
ICU noise and light.
Critical Care, 2015, 19:124 March 19, 2015
Ed: This is a powerful result, considering that only 1
mg melatonin was used. Typical recommendations are
0.5 to 10 mg per day, taken around 9 PM. Unlike very
addictive benzodiazapines and hypnotics, melatonin
does NOT cause addiction and rebound anxiety, and
is safe for long-term use. Melatonin is produced from
serotonin in the body naturally, but this conversion
has been found to be insufficient in many people.
According to the Mayo Clinic, for sleep disorders in
people with behavioral, developmental, or mental disorders, 0.1-10 milligrams of melatonin has been taken
by mouth daily for up to one year. The Mayo website
reports benefits for those with macular degeneration,
body temperature regulation, Alzheimer’s, inflammation, asthma, benzo withdrawal, cancer, chronic
fatigue syndrome, COPD, circadian sleep disorders,
delayed sleep phase syndrome, delirium, depression,
fibromyalgia, stomach and intestinal disorders, headache, liver inflammation, hypertension, high cholesterol, insomnia, jet lag, memory improvement, exercise
performance, menopause, Parkinson’s, periodic limb
movement disorder, REM sleep behavior disorder,
restless leg syndrome, sarcoidosis, schizophrenia,
seasonal affective disorder, seizure disorder, autism,
cystic fibrosis, dialysis, traumatic brain injury, smokers, surgery patients, tardive dyskinesia, low platelets,
ringing in the ears, ulcers, nightime urination, work
shift sleep disorder, and sunburn. See recommended
dosages at http://www.mayoclinic.org/drugs-supplements/melatonin/dosing/hrb-20059770
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Psychology Has Important Role in Changing
Cancer Landscape
about which components are needed to achieve positive outcomes.
Psychology has played, and will continue to play, a
critical role in cancer prevention, treatment and control, according to the flagship journal of the American
Psychological Association.
“Up to one-third of the annual cancer diagnoses in the
U.S. are attributable in part to risk factors like tobacco
use, obesity, physical inactivity and poor nutrition,”
according to Paige Green McDonald, PhD, MPH, one
of the three scholarly leads on the issue. “Psychological science and evidence-based practice are making
important contributions to address the pressing needs
of people with cancer.”
To evaluate the importance of the skills training component of DBT by comparing skills training plus case
management (DBT-S), DBT individual therapy plus
activities group (DBT-I), and standard DBT which
includes skills training and individual therapy, we
performed a single-blind randomized clinical trial from
April 24, 2004, through January 26, 2010, involving 1
year of treatment and 1 year of follow-up. Participants
included 99 women (mean age, 30.3 years; 69 [71%]
white) with borderline personality disorder who had
at least 2 suicide attempts and/or nonsuicidal selfinjury (NSSI) acts in the last 5 years, an NSSI act or
suicide attempt in the 8 weeks before screening, and
a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to
each condition. Treatment was delivered from June 3,
2004, through September 29, 2008, in a universityaffiliated clinic and community settings by therapists
or case managers. Outcomes were evaluated quarterly
by blinded assessors. We hypothesized that standard
DBT would outperform DBT-S and DBT-I.
The other scholarly leads on the issue were Russell
Glasgow, PhD, with the University of Colorado School
of Medicine, and Jerry Suls, PhD. Suls and Green
McDonald work for the Behavioral Research Program
in the Division of Cancer Control and Population Sciences at the National Cancer Institute.
The study compared standard DBT, DBT-S, and DBTI. Treatment dose was controlled across conditions,
and all treatment providers used the DBT suicide risk
assessment and management protocol. Main Outcomes and measures were frequency and severity of
suicide attempts and NSSI episodes.
“As evidence linking certain behaviors to cancer risk
and outcomes accumulated, psychology emerged as a
‘hub science’ in the nation’s cancer control program,”
according to the article “Cancer Control Falls Squarely
Within the Province of the Psychological Sciences.”
Psychology helps people learn to modify unhealthy behaviors that can lead to disease, and enhances the lives
of people who have survived or are living with cancer.
All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to
suicidality, and reasons for living. Compared with the
DBT-I group, interventions that included skills training resulted in greater improvements in the frequency
of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT
and F1,85 = 56.3 [P < .001] for DBT-S) and depression
(t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = −3.5 [P < .001]) and
DBT-S (t94 = −2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group
had lower dropout rates from treatment (8 patients
[24%] vs 16 patients [48%] [P = .04]), and patients
were less likely to use crisis services in follow-up (ED
visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]).
In a special issue of American Psychologist® entitled
“Cancer and Psychology,” researchers review the many
contributions of psychological science to cancer research, screening, medical adherence, prevention and
quality of life, among other related topics. The issue
highlights the discoveries and accomplishments that
have rooted the psychological sciences as one pillar of
cancer control research, practice and policy.
APA March 2, 2015
Dialectical Behavior Therapy for High Suicide
Risk in Individuals With Borderline Personality Disorder
Dialectical behavior therapy (DBT) is an empirically
supported treatment for suicidal individuals. However, DBT consists of multiple components, including
individual therapy, skills training, telephone coaching,
and a therapist consultation team, and little is known
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Conclusions; A variety of DBT interventions with
therapists trained in the DBT suicide risk assessment
and management protocol are effective for reducing
suicide attempts and NSSI episodes. Interventions
that include DBT skills training are more effective than
DBT without skills training, and standard DBT may be
superior in some areas.
JAMA Psychiatry. Published online March 25, 2015
Bisphenol A Exposure in Children With Autism
Spectrum Disorder
The etiology of autism spectrum disorders (ASD) is
believed to involve genetic and environmental components. This study focused on the plasticizer, BisphenolA (BPA). The major pathway for BPA metabolism and
excretion is via glucuronidation. To determine whether
there was a relationship between BPA exposure and
ASD, urine specimens were collected from 46 children
with ASD and 52 controls. Free and total BPA concentrations were determined by mass spectrometry. The
fraction glucuronidated was calculated from the difference. A metabolomics study was done to investigate
metabolite distribution in the urine. (i) Most of the
BPA excreted in the urine was as the glucuronide; (ii)
about 20% of the ASD children had BPA levels beyond
the 90th percentile (>50 ng/mL) of the frequency
distribution for the total sample of 98 children; (iii)
Mann–Whitney U tests and multiple regression analyses found significant differences (P < 0.05) between the
groups in total and % bound BPA; and (iv) the metabolomics analyses showed the number of absolute partial
correlations >|0.30| between metabolite concentrations and total BPA was 3 times greater with the ASD
group than the controls (P < 0.001), and the number of
absolute partial correlations > |0.30| for % bound BPA
was 15 times higher with ASD (P < 0.001).
Conclusions: The results suggest there is an association between BPA and ASD.
Autism Res January 2015.
Neurobehavioral Deficits, Diseases and Associated Costs of Exposure to Endocrine Disrupting Chemicals in the European Union
Epidemiological studies and animal models demonstrate that endocrine disrupting chemicals (EDCs)
contribute to cognitive deficits and neurodevelopmental disabilities.
Objective: To estimate neurodevelopmental disability
and associated costs that can be reasonably attributed
to EDC exposure in the European Union.
Design: An expert panel applied a weight-of-evidence
characterization adapted from the Intergovernmental
Panel on Climate Change. Exposure-response relationships and reference levels were evaluated for relevant
EDCs, and biomarker data were organized from peerreviewed studies to represent European exposure and
approximate burden of disease. Cost estimation as of
2010 utilized lifetime economic productivity estimates,
lifetime cost estimates for autism spectrum disorder
(ASD) and annual costs for attention deficit hyperactivity disorder (ADHD).
Cost estimation was carried out from a societal perspective, i.e. including direct costs (e.g. treatment
costs) and indirect costs such as productivity loss.
The panel identified 70–100% probability that polybrominated diphenyl ether (PBDE) and organophosphate (OP) exposures contribute to IQ loss in the
European population. PBDE exposures were associated with 873,000 (sensitivity analysis: 148,000–2.02
million) lost IQ points and 3,290 (sensitivity analysis:
3,290–8,080) cases of intellectual disability, at costs of
€9.59 billion (sensitivity analysis: €1.58–22.4 billion).
OP exposures were associated with 13.0 billion (sensitivity analysis: 4.24–17.1 billion) lost IQ points and
59,300 (sensitivity analysis: 16,500–84,400) cases of
intellectual disability, at costs of €146 billion (sensitivity analysis: €46.8–194 billion). ASD causation by multiple EDCs was assigned a 20–39% probability, with
316 (sensitivity analysis: 126–631) attributable cases at
a cost of €199 million (sensitivity analysis: €79.7–399
million). ADHD causation by multiple EDCs was assigned a 20–69% probability, with 19,300–31,200
attributable cases at a cost of €1.21–2.86 billion.
Conclusions: EDC exposures in Europe contribute
substantially to neurobehavioral deficits and disease,
with a high probability of >€150 billion costs/year.
These results emphasize the advantages of controlling
EDC exposure.
The Journal of Clinical Endocrinology & Metabolism
March 5, 2015
Ed: The European Union defines an endocrinedisrupting chemical as an “exogenous substance that
causes adverse health effects in an intact organism or
its progeny, secondary to changes in endocrine func-
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
33
Science Notes- Alternative Approaches
tion.” In all, 13 chronic conditions have strong scientific evidence for causation by endocrine-disrupting
chemicals.
Endocribe disruptors include pharmaceuticals, industrial solvents, personal-care products, aluminum-can
linings, plasticizers, pesticides, and environmental pollutants. Chemicals known to be endocrine disrupting
include diethylstilbestrol, polychlorinated biphenyls
(PCBs) , dioxins, perfluoroalkyl compounds, solvents,
phthalates, bisphenol A (BPA), dichlorodiphenyldichloroethylene organophosphate/organochlorine
pesticides, and polybrominated diphenyl.
According to the author, “There are safe and simple
steps that families can take to limit their exposure to
endocrine-disruptive chemicals. They can avoid microwaving plastic. They can avoid eating from aluminum
cans or drinking fluids from aluminum cans. They can
eat organic. Or even simply air out their homes every
couple of days to remove some of the chemical dust…
that can disrupt hormones in their bodies.”
Men Referred for Borderline Testosterone Levels Have High Rates of Depression
Studies have shown inconsistent results regarding a
possible association between depression and serum
testosterone levels. There are few published studies on
adult men who are referred for management of borderline testosterone levels, although this is a very common
clinical scenario. We hypothesized that men referred
for borderline testosterone levels would have higher
rates of depression and depressive symptoms than the
general population.
Methods: Subjects were 200 adult men (age range
20-77 years old) referred for management of borderline testosterone levels, defined as total testosterones
between 200-350 ng/dl (6.9-12 nmol/L). All men
had a repeat measurement of total testosterone and
an assessment of depressive symptoms or depression
[scores from the validated Patient Health Questionnaire 9 (PHQ-9) and/or an established diagnosis of
depression or current use of an antidepressant]. Collected data included demographic information, medical histories, medication use, and signs and symptoms
of hypogonadism.
Results: Using a score of ≥10 on the PHQ-9, 56% of the
population had either significant depressive symptoms
and/or a known diagnosis of depression and/or use of
an antidepressant. The PHQ-9 identified depressive
symptoms (scores ≥10) in 7% of the study population
in which these men denied depressive symptoms or
having depression. Men referred for borderline total
testosterone levels had rates of depressive symptoms
that were markedly higher than those seen in several
reference populations using the same validated instrument. For example, rates of depressive symptoms
(PHQ9 scores ≥10) ranged from 15-22% in an ethnically diverse sample of primary care patients and was
5.6% among overweight and obese US adults from the
2005-6 NHANES. The population was also notable
for a high prevalence of overweight (39%), obesity
(40%) and physical inactivity as over half (51%) did not
engage in regular exercise that did not involve walking.
The most common symptoms reported were erectile
dysfunction (78%), low libido (69%) and low energy
(52%).
Conclusions: Men referred for borderline testosterone
levels have higher rates of depression and depressive
symptoms than the general population. This study underscores the utility of a validated instrument to screen
for depression, especially as some subjects may deny
signs and symptoms during the interview. Appropriate referrals should be made for formal evaluation and
treatment of depression.
Endocrine Society Poster 97tyh annual meeting and
expo.
Ed: Yet another physical cause of depression.
There have been no reports that SSRIs or other
“anti”depressants increase testosterone, so they should
never be the first course of action when depression is
detected.
Corporal Punishment, Maternal Warmth, and
Child Adjustment: A Longitudinal Study in
Eight Countries
Two key tasks facing parents across cultures are managing children’s behaviors (and misbehaviors) and
conveying love and affection. Previous research has
found that corporal punishment generally is related
to worse child adjustment, whereas parental warmth
is related to better child adjustment. This study examined whether the association between corporal
punishment and child adjustment problems (anxiety
and aggression) is moderated by maternal warmth
in a diverse set of countries that vary in a number of
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
34
Science Notes- Alternative Approaches
sociodemographic and psychological ways. Interviews
were conducted with 7- to 10-year-old children (N
= 1,196; 51% girls) and their mothers in 8 countries:
China, Colombia, Italy, Jordan, Kenya, the Philippines,
Thailand, and the United States. Follow-up interviews
were conducted 1 and 2 years later. Corporal punishment was related to increases, and maternal warmth
was related to decreases, in children’s anxiety and aggression over time; however, these associations varied
somewhat across groups. Maternal warmth moderated the effect of corporal punishment in some countries, with increases in anxiety over time for children
whose mothers were high in both warmth and corporal
punishment. The findings illustrate the overall association between corporal punishment and child anxiety
and aggression as well as patterns specific to particular countries. Results suggest that clinicians across
countries should advise parents against using corporal
punishment, even in the context of parent–child relationships that are otherwise warm, and should assist
parents in finding other ways to manage children’s
behaviors.
Journal of Clinical Child & Adolescent Psychology Volume 43, Issue 4, 2014
Effectiveness of Traditional Chinese Medicine
as an Adjunct Therapy for Parkinson’s Disease:
A Systematic Review and Meta-Analysis
Idiopathic Parkinson disease (PD) is a common neurodegenerative disease that seriously hinders limb
activities and affects patients’ lives. We performed
a meta-analysis aiming to systematically review and
quantitatively synthesize the efficacy and safety of
traditional Chinese medicine (TCM) as an adjunct
therapy for clinical PD patients.
An electronic search was conducted in PubMed,
Cochrane Controlled Trials Register, China National
Knowledge Infrastructure, Chinese Scientific Journals
Database and Wanfang data to identify randomized
trials evaluating TCM adjuvant therapy versus conventional treatment. The change from baseline of the Unified Parkinson’s Disease Rating Scale score (UPDRS)
was used to estimate the effectiveness of the therapies.
Twenty-seven articles involving 2314 patients from
1999 to 2013 were included. Potentially marked improvements were shown in UPDRS I (SMD 0.68,
95%CI 0.38, 0.98), II (WMD 2.41, 95%CI 1.66, 2.62),
III (WMD 2.45, 95%CI 2.03, 2.86), IV (WMD 0.32,
95%CI 0.15, 049) and I-IV total scores (WMD 6.18,
95%CI 5.06, 7.31) in patients with TCM plus dopamine
replacement therapy (DRT) compared to DRT alone.
Acupuncture add-on therapy was markedly beneficial for improving the UPDRS I–IV total score of PD
patients (WMD 10.96, 95%CI 5.85, 16.07). However,
TCM monotherapy did not improve the score. The effectiveness seemed to be more obvious in PD patients
with longer adjunct durations. TCM adjuvant therapy
was generally safe and well tolerated.
Conclusions: Although the data were limited by methodological flaws in many studies, the evidence indicates the potential superiority of TCM as an alternative therapeutic for PD treatment and justifies further
high-quality studies.
Ed: The characteristic symptoms of Parkinson’s appeared in ancient Chinese medical texts that described
trembling of the hands and shaking of the head. The
disorder and its basis has been subjected to considerable analysis over the centuries. Syndromes in which
elderly patients suffer from spontaneous shaking, or
from other muscular manifestations such as paralysis or tonic spasm, are thought to be the result of yin
deficiency of the kidney and liver leading to generation
of “internal wind.”
The most common formula/herbs used in these studies
was Guiling Pa’an, which contains:
Dang shen
Dried root of Codonopsis pilosula
Dried root tuber of Rehmannia gluti
Sheng di
nosa
Fu ling
Dried sclerotium of the fungus, Poria cocos
Gou teng
Dried hook-bearing stem branch of Un
caria rhynchophylla
Bai Zhu
Rhizome of Atractylodes macrocephala
Koidz
Dried root of Angelica sinensis
Dang gui
Fa ban xia
Dried tuber of Pinelliae ternate
Chuan xiong Dried rhizome of Ligusticum chuanx
iong
Huai niu xi Dried root of Achyranthes bidentata
Chen pi
Dried pericarp of the ripe fruit of Citrus reticulata ]
Sheng gan caoDried root and rhizome of Glycyrrhiza uralensis
Contact the editor for guidance on using TCM preparations with your patients.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
35
Follow @BehavioralNews on
Stay up to date on #Behavioral medicine, #Psychopharmacology #Healthcare,
#Integration, #NAPPP, #RxP, and #Conference news.
Here’s a sample of news stories from this past month:
Team finds key to making neurons from stem cells @Medical_Xpress
A research team at UC San Francisco has discovered an RNA molecule called Pnky that can be manipulated
to increase the production of neurons from neural stem cells. The research, led by neurosurgeon Daniel A. Lim,
MD, PhD, and published on March 19, 2015 in Cell Stem Cell, has possible applications in regenerative
medicine, including treatments of such disorders as Alzheimer's disease, Parkinson's disease and traumatic
brain injury, and in cancer treatment. Pnky is one of a number of newly discovered long noncoding RNAs
(lncRNAs), which are stretches of 200 or more nucleotides in the human genome that do not code for proteins,
yet seem to have a biological function. The name, pronounced "Pinky," was inspired by the popular American
cartoon series Pinky and the Brain. "Pnky is encoded near a gene called 'Brain,' so it sort of suggested itself to
the students in my laboratory," said Lim. Pnky also appears only to be found in the brain, he noted. Co-first
authors Alex Ramos, PhD, and Rebecca Andersen, who are students in Lim's laboratory, first studied Pnky in
neural stem cells found in mouse brains, and also identified the molecule in neural stem cells of the developing
human brain. They found that when Pnky was removed from stem cells in a process called knockdown, neuron
production increased three to four times. "It is remarkable that when you take Pnky away, the stem cells
produce many more neurons," said Lim, an assistant professor of neurological surgery and director of
restorative surgery at UCSF. "These findings suggest that Pnky, and perhaps lncRNAs in general, could
eventually have important applications in regenerative medicine and cancer treatment."
Attention Caregivers: Antipsychotic Drugs Increase Dementia Patients’ Risk of Death Rebecca Hiscott
@NeurologyNow
Progressive memory loss is a hallmark symptom of Alzheimer’s disease, the most common form of dementia,
but many patients also experience a slew of behavioral and psychological symptoms such as depression,
anxiety, aggressiveness, the propensity to wander off, sleep problems, and even psychosis, hallucinations, and
delusions. Many doctors prescribe antipsychotic drugs like haloperidol (Haldol), olanzapine (Zyprexa),
quetiapine (Seroquel), and risperidone (Risperdal) for symptoms like aggression, anxiety and delusions, despite
warnings from researchers that antipsychotics are risky for dementia patients. Now, a new study published in
the journal JAMA Psychiatry suggests the risks are even greater than previously thought. Researchers from the
University of Michigan analyzed a group of 90,786 American veterans over age 65 who were diagnosed with
dementia and enrolled in the Veterans Health Administration between October 1998 and September 2009.
Each patient taking an antipsychotic medication—46,008 in all—was compared with a patient of the same
age who wasn’t on an antipsychotic drug. The researchers found that patients who took antipsychotics were
more likely to die during the six-month period after receiving the prescription than those who did not take an
antipsychotic. There was a 3.8 percent increased risk of death for patients on haloperidol (which translates to
one additional death for every 26 patients receiving the drug), a 3.7 percent increased risk with risperidone, a
2.5 percent increased risk with olanzapine, and a 2 percent increased risk with quetiapine. Dosage also
mattered: Patients taking higher doses of olanzapine, quetiapine, or risperidone had a 3.5 percent higher risk
of death than patients taking lower doses of these drugs. Past studies have pointed to similar results, and the
@BehavioralNews
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36
US Food and Drug Administration (FDA) has issued official warnings that these drugs carry risks for dementia
patients. But the new study shows even higher rates of risk than previously reported, said study author
Donovan Maust, MD, MS, a psychiatrist at the University of Michigan Medical School and Veterans Affairs
Center for Clinical Management Research, in a news release.
Antibodies to brain proteins may trigger psychosis @MNT_psychology
Antibodies defend the body against bacterial, viral, and other invaders. But sometimes the body makes
antibodies that attack healthy cells. In these cases, autoimmune disorders develop. Immune abnormalities in
patients with psychosis have been recognized for over a century, but it has been only relatively recently that
scientists have identified specific immune mechanisms that seem to directly produce symptoms of psychosis,
including hallucinations and delusions. This 'immune hypothesis' is supported by new work published by
Pathmanandavel and colleagues in Biological Psychiatry. They detected antibodies to the dopamine D2
receptor or the N-methyl-D-aspartate (NMDA) glutamate receptor in a subgroup of children experiencing their
first episode of psychosis, but no such antibodies in healthy children. Both are key neural signaling proteins
that have previously been implicated in psychosis. "The antibodies we have detected in children having a first
episode of acute psychosis suggest there is a distinct subgroup for whom autoimmunity plays a role in their
illness," said Dr. Fabienne Brilot, senior author on the article and Head of the Neuroimmunology Group at The
Children's Hospital at Westmead in Sydney. It almost seems like a dirty trick. For decades psychiatrists have
administered drugs that stimulate dopamine D2 receptors or block NMDA receptors. These drugs may briefly
produce side effects that resemble symptoms of psychotic disorders, including changes in perception,
delusions, and disorganization of thought processes. The current findings suggest that people may develop
antibodies that affect the brain in ways that are similar to these psychosis-producing drugs. "This study adds
fuel to the growing discussions about the importance of antibodies targeting neural proteins and it raises
many important questions for the field. Do these antibodies simply function like drugs in the brain or do they
'attack' and damage nerve cells in some ways?" questioned Dr. John Krystal, Editor of Biological Psychiatry.
"Also, are these antibodies producing symptoms in everyone or do they function as a probe of an underlying,
perhaps genetic, vulnerability for psychosis?"
Potential new drug target may protect against certain neurodegenerative diseases @Medical_Xpress
Penn Medicine researchers have discovered that hypermethylation - the epigenetic ability to turn down or turn
off a bad gene implicated in 10 to 30 percent of patients with Amyotrophic Lateral Sclerosis (ALS) and
Frontotemporal Degeneration (FTD) - serves as a protective barrier inhibiting the development of these
diseases. Their work, published this month in Neurology, may suggest a neuroprotective target for drug
discovery efforts. "This is the first epigenetic modification of a gene that seems to be protective against
neuronal disease," says lead author Corey McMillan, PhD, research assistant professor of Neurology in the
Frontotemporal Degeneration Center in the Perelman School of Medicine at the University of Pennsylvania.
Expansions in the offending gene, C9orf72, have been linked with TAR DNA binding protein (TDP-43) which is
the pathological source that causes ALS and FTD. "Understanding the role of C9orf72 has the possibility to be
truly translational and improve the lives of patients suffering from these devastating diseases," says senior
author, Edward Lee, MD, PhD, assistant professor of Neuropathology in Pathology and Laboratory Medicine
at Penn. McMillan and team evaluated 20 patients recruited from both the FTD Center and the ALS Center at
the University of Pennsylvania who screened positive for a mutation in the C9orf72 gene and were clinically
diagnosed with FTD or ALS. All patients completed a neuroimaging study, a blood test to evaluate C9orf72
methylation levels, and a brief neuropsychological screening assessment. The study also included 25 heathy
controls with no history of neurological or psychiatric disease. MRI revealed reduced grey matter in several
regions that were affected in patients compared to controls. Grey matter is needed for the proper function of
the brain in regions involved with muscle control, memory, emotions, speech and decision-making. Critically,
@BehavioralNews
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37
patients with hypermethylation of C9orf72 showed more dense grey matter in the hippocampus, frontal
cortex, and thalamus, regions of the brain important for the above described tasks and affected in ALS and
FTD, suggesting that hypermethylation is neuroprotective in these regions.
Omega-3 fatty acids and vitamin D may control brain serotonin @MNT_psychology
Although essential marine omega-3 fatty acids and vitamin D have been shown to improve cognitive function
and behavior in the context of certain brain disorders, the underlying mechanism has been unclear. In a new
paper published in FASEB Journal by Rhonda Patrick, PhD and Bruce Ames, PhD of Children's Hospital
Oakland Research Institute (CHORI), serotonin is explained as the possible missing link tying together why
vitamin D and marine omega-3 fatty acids might ameliorate the symptoms associated with a broad array of
brain disorders. In a previous paper published last year, authors Patrick and Ames discussed the implications
of their finding that vitamin D regulates the conversion of the essential amino acid tryptophan into serotonin,
and how this may influence the development of autism, particularly in developing children with poor vitamin
D status. Here they discuss the relevance of these micronutrients for neuropsychiatric illness. Serotonin affects
a wide-range of cognitive functions and behaviors including mood, decision-making, social behavior,
impulsive behavior, and even plays a role in social decision-making by keeping in check aggressive social
responses or impulsive behavior. Many clinical disorders, such as autism spectrum disorder (ASD), attention
deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia, and depression share as a unifying
attribute low brain serotonin. "In this paper we explain how serotonin is a critical modulator of executive
function, impulse control, sensory gating, and pro-social behavior," says Dr. Patrick. "We link serotonin
production and function to vitamin D and omega-3 fatty acids, suggesting one way these important
micronutrients help the brain function and affect the way we behave." Eicosapentaenoic acid (EPA) increases
serotonin release from presynaptic neurons by reducing inflammatory signaling molecules in the brain known
as E2 series prostaglandins, which inhibit serotonin release and suggests how inflammation may negatively
impact serotonin in the brain. EPA, however, is not the only omega-3 that plays a role in the serotonin
pathway. Docosahexaenoic acid (DHA) also influences the action of various serotonin receptors by making
them more accessible to serotonin by increasing cell membrane fluidity in postsynaptic neurons.
Autistic and non-autistic brain differences isolated for first time @Medical_Xpress
The functional differences between autistic and non-autistic brains have been isolated for the first time,
following the development of a new methodology for analysing MRI scans. Developed by researchers at the
University of Warwick, the methodology, called Brain-Wide Association Analysis (BWAS), is the first capable
of creating panoramic views of the whole brain and provides scientists with an accurate 3D model to study.
The researchers used BWAS to identify regions of the brain that may make a major contribution to the
symptoms of autism. BWAS does so by analysing 1,134,570,430 individual pieces of data; covering the 47,636
different areas of the brain, called voxels, which comprise a functional MRI (fMRI) scan and the connections
between them. Previous methodologies were process this level of data and were restricted to modelling only
limited areas. The ability to analyse the entire data set from an fMRI scan provided the Warwick researchers
the opportunity to compile, compare and contrast accurate computer models for both autistic and nonautistic brains. Led by BWAS developer Professor Jianfeng Feng, from the University of Warwick's Department
of Computer Science, the researchers collected the data from hundreds of fMRI scans of autistic and nonautistic brains. By comparing the two subsequent models the researchers isolated twenty examples of
difference, where the connections between voxels of the autistic brain were stronger or weaker than the nonautistic . The identified differences include key systems involved with brain functions relating to autism.
Professor Feng explained the findings: "We identified in the autistic model a key system in the temporal lobe
visual cortex with reduced cortical functional connectivity. This region is involved with the face expression
processing involved in social behaviour. This key system has reduced functional connectivity with the
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ventromedial prefrontal cortex, which is implicated in emotion and social communication". The researchers
also identified in autism a second key system relating to reduced cortical functional connectivity, a part of the
parietal lobe implicated in spatial functions.
Early life stress may cause excess serotonin release resulting in a serotonin deficit @MNT_psychology
Studies indicate that the majority of people with mood and anxiety disorders who receive the most commonly
prescribed class of antidepressant medications, Selective Serotonin Reuptake Inhibitors or SSRI's, are not
helped by these medications. SSRIs are designed to increase serotonin, a neurotransmitter in the brain that is
key to maintenance of mood. Researchers led by Jeremy D. Coplan, MD, professor of psychiatry at SUNY
Downstate Medical Center, have published data suggesting an explanation for the longstanding puzzle as to
why low serotonin could not be detected in depression without suicidal intent, even though many
antidepressant treatments work by increasing serotonin in areas key for mood regulation, such as the
hippocampus. The pre-clinical research was published in a recent edition of Frontiers in Behavioral
Neuroscience. Dr. Coplan explains, "We have shown that serotonin is too high near the serotonin brain cells,
reducing firing of the serotonin nerve cells through a well-documented negative feedback mechanism in the
raphe nucleus. The result is that the hippocampus and other critical brain structures needed for mood
maintenance do not get enough serotonin. We can see this because the hippocampus is shrunken and the
white matter loses integrity. By the time serotonin metabolites are measured in a lumbar spinal tap, the usual
way serotonin levels have been measured, the high serotonin has mixed with the low serotonin and you have
no difference from people who are healthy." He continues, "We have hypothesized in an earlier paper that this
is a plausible reason why SSRIs may not work in a majority of people, because SSRIs will tend to make the
high serotonin even higher in the raphe nucleus. The serotonin neuron may not be able to adapt and restore its
firing, inducing a presumed serotonin deficit in terminal fields, evidenced by shrinkage of the hippocampus."
Autism-Linked Genes May Be Tied to Slightly Higher IQ HealthDay.com
Genes believed to increase the risk of autism may also be linked with higher intelligence, a new study suggests.
Researchers analyzed the DNA of nearly 10,000 people in Scotland and also tested their thinking abilities.
On average, those who had genes associated with autism scored slightly higher on the thinking (cognitive)
tests. Having autism-linked genes doesn't mean that people will develop the disorder, the researchers noted.
Similar evidence of an association between autism-linked genes and intelligence was found in previous testing
of 921 teens in Australia, according to the study published March 10 in the journal Molecular Psychiatry. "Our
findings show that genetic variation which increases risk for autism is associated with better cognitive ability in
non-autistic individuals," said study leader Toni-Kim Clarke, of the University of Edinburgh in Scotland. "As we
begin to understand how genetic variants associated with autism impact brain function, we may begin to
further understand the nature of autistic intelligence," Clarke said in a university news release. Another
researcher went further. "This study suggests genes for autism may actually confer, on average, a small
intellectual advantage in those who carry them, provided they are not affected by autism," Nick Martin, head
of the Genetic Epidemiology Laboratory at the Queensland Institute for Medical Research in Australia, said in
the news release. While 70 percent of people with autism have intellectual disabilities, some people with the
disorder have higher-than-average nonverbal intelligence, the study authors noted.
Oxytocin may enhance social function in psychiatric disorders @MNT_psychology
Researchers at the Yerkes National Primate Research Center, Emory University, have shown inducing the
release of brain oxytocin may be a viable therapeutic option for enhancing social function in psychiatric
disorders, including autism spectrum disorders and schizophrenia. The study results are published in the
advance online edition of Neuropsychopharmacology. The oxytocin system is well-known for creating a bond
between a mother and her newborn baby, and oxytocin is a lead drug candidate for treating social deficits in
@BehavioralNews
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39
autism. Getting synthetic oxytocin into the brain, however, is challenging because of a blood-brain barrier. In
this new study, lead researchers Meera Modi, PhD, and Larry Young, PhD, demonstrated for the first time the
potential of oxytocin-releasing drugs to activate the social brain, to create bonds and, they believe, to possibly
treat social deficits in psychiatric disorders. Meera, who is now at Pfizer, was a graduate student at the Yerkes
Research Center when she worked with Young on this research. Young is division chief of Behavioral
Neuroscience and Psychiatric Disorders at the Yerkes National Primate Research Center, William P. Timmie
professor in the Emory School of Medicine Department of Psychiatry, director of the Center for Translational
Social Neuroscience at Emory and principal investigator and director of the NIH Silvio O. Conte Center at
Emory. The researchers used pair bonding in monogamous prairie voles as an index of prosocial effects.
Normally mating in the voles is necessary for the release of brain oxytocin that leads to a monogamous bond.
For the first time, however, the Yerkes researchers showed that a drug that activates melanocortin receptors
stimulates release of oxytocin in the brain to affect social relationships. According to Young, a simple injection
of the melanocortin drug quickly induced a pair bond in male and female prairie voles without mating, and
that bond lasted long after the drug wore away. The researchers also showed the same drug activated
oxytocin cells so the cells released oxytocin directly into the brain's reward centers responsible for generating
bonds.
New images of the brain show the forgetful side effect of frequent recall @Medical_Xpress
A new study from the University of Birmingham and the MRC Cognition and Brain Sciences unit in Cambridge
has shown how intentional recall is beyond a simple reawakening of a memory; and actually leads us to
forget other competing experiences that interfere with retrieval. Quite simply, the very act of remembering may
be one of the major reasons why we forget. The research, published today in Nature Neuroscience, is the first
to isolate the adaptive forgetting mechanism in the human brain. The brain imaging study shows that the
mechanism itself is implemented by the suppression of the unique cortical patterns that underlie competing
memories. Via this mechanism, remembering dynamically alters which aspects of our past remain accessible.
Dr Maria Wimber, from the University of Birmingham, explained, "Though there has been an emerging belief
within the academic field that the brain has this inhibitory mechanism, I think a lot of people are surprised to
hear that recalling memories has this darker side of making us forget others by actually suppressing them."
Patterns of brain activity in the participants were monitored by MRI scans while they were asked to recall
individual memories based on images they had been shown earlier. The team, co-led by Dr Michael Anderson
from the MRC Cognition and Brain Sciences Unit Cambridge, were able to track the brain activity induced by
individual memories and show how this supressed others by dividing the brain into tiny 3-dimensional voxels.
Based on the fine-grained activation patterns of these voxels, the researchers were able to witness the neural
fate of individual memories as they were reactivated initially, and subsequently suppressed. Over the course of
four selective retrievals the participants in the study were cued to retrieve a target memory, which became
more vivid with each trial. Competing memories were less well reactivated as each trial was carried out, and
indeed were pushed below baseline expectations for memory, supporting the idea that an active suppression
of memory was taking place.
Beliefs about nicotine 'may override its effects on the brain' @MNT_psychology
Nicotine replacement therapy and prescription medications such as varenicline are often used as smoking
cessation aids. But a new study suggests there may be another way to quit the habit: by manipulating the brain's
reward system through beliefs. Published in the Proceedings of the National Academy of Sciences, the study
revealed that participants who were told their cigarettes contained no nicotine showed less activity in areas of the
brain that drive addiction - the reward-learning pathways, suggesting that an individual's beliefs about nicotine
may influence a person's addiction to it. Smoking is the leading preventable cause of death in the US. While it is
other toxic agents in tobacco that are responsible for the damaging health effects of smoking, it is nicotine that
causes tobacco addiction. According to the research team, led by Read Montague,
director of the
@BehavioralNews
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Computational Psychiatry Unit at the Virginia Tech Carillon Research Institute, nicotine stimulates neural
pathways in the brain associated with pleasure and reward, which is what drives nicotine addiction. In their study,
Montague and his team set out to investigate whether smokers' beliefs about nicotine, rather than their actual
nicotine intake, could modify activity in reward-learning pathways of the brain. The researchers point out that
beliefs are known to contribute to the "placebo effect" - the idea that a "sham" treatment will have a positive effect
based on the expectation that it will. "A subject's belief that he or she is receiving a treatment could lead to
observable improvement even in the absence of active drugs," the authors note. "These treatment effects are
putatively accomplished by neurobiological processes usually associated with pharmacological actions of active
drugs, even though active drugs are not administered."
@BehavioralNews
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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April Continuing Education Credit
By Gary Traub, Ph.D.
Get one hour of CE credit by reading this edition of
TCP and completing the following questions. E-mail
your answers to Dr. John Caccavale, NAPPP,
at [email protected]
1.
In the lead article, regarding the Dunning-Kruger effect,
it is stated that the problematic aspect of incompetence is that
you have a group of people who are completely unaware of their
incompetence, and when considering the cognitive dissonance
factor, they dig in their heels to justify their position. True/false
14.
The practice guidelines state that antidepressants should
not be prescribed as an initial treatment in children and young
people for mild depression. True/false
15.
In moderate to severe depression, children and young
people should experience a psychological therapy for at least
three months which could include CBT, interpersonal therapy,
family therapy, or psychodynamic therapy. True/false
16.
The only antidepressant licensed for use in depression in
young people is _______________.
2.
Dunning actually stated that an ignorant mind is a
spotless, empty vessel. True/false
17.
The majority of people who hear voices actually here
multiple voices with distinct character like qualities. True/false
3.
The author states that the science of psychology is
actually a “soft” science. True/false
18.
There are people who hear voices that do not have a
psychiatric diagnosis. True/false
4.
Evidence-based therapies have been relatively easy to
develop for psychology. True/false
19.
It is estimated that between _______ percent and
_______ percent of adults will experience auditory hallucinations
during their lifetimes.
5.
A landmark study has now demonstrated that
psychologists who graduate from APA accredited programs
provide more quality services than those who do not. True/false
6.
The Examination for the Professional Practice in
Psychology is somewhat disappointing in regard to its reliability
and validity. True/false
7.
Recently, the deans of some of the most prestigious law
schools are questioning the reliability and validity of the State Bar
exam. True/false
8.
Mental health administrators are generally paid
considerably better than mental health professionals. True/false
9.
The lack of psychiatrists has led to a significant increase
in advance practiced registered nurses, physician assistants, and
family practitioners who practice psychopharmacology. True/false
20.
Alzheimer’s disease begins when a specific protein starts
breaking, or cleaving, at the one place to produce an unwanted
fragment, called BAP. True/false
21.
_______________, commonly used to treat epilepsy,
calms hyperactivity in the brain of patients with amnestic mild
cognitive impairment.
22.
Antipsychotic drugs are frequently prescribed to older
adults with dementia, and in some cases the benefits appear to
outweigh the risks. True/false
23.
Cholinesterase inhibitors are thought to delay the
progression of Alzheimer’s disease. True/false
24.
false
Namenda can cause Stevens Johnson syndrome. True/
10.
Intensive individual treatment is the treatment of choice
for borderline personality disorder. True/false
25.
Melatonin does not cause addiction and rebound anxiety,
and is safe for long-term use. True/false
11.
The content of licensure exams for entry-level practice
should focus on psychology, and leave “medical literacy” to the
other professions. True/false
Men referred for borderline testosterone levels have
26.
higher rates of depression than the general population. True/false
12.
According to practice guidelines from the British
medical Journal, there is now clear evidence that favor certain
psychological therapies over others. True/false
13.
Psychosocial risk factors for depression include such
things as age, gender, family discord, bullying, abuse, substance
abuse, co-morbid disorders, and a history of parental depression.
True/false
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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Current Listing of Free CE Courses
The following courses are now available free with NAPPP membership. CE credit is provided by NAPPP and alliance
partners who are approved sponsors of continuing education by the National Institute of Behavioral Health Quality
and the American Psychological Association. Many states require specific courses for licensure and license renewal.
NAPPP courses are designed to meet these requirements. However, members should check with their state statutes
to determine specific CE requirements. Contact Dr. Caccavale for details at [email protected]
Psy #1 - Pharmacotherapeutics: 10 CE credit
hours
Integration of the principles of psychology in the
application of pharmacological agents in the alleviation
of mental health concerns.
Psy #2 - Neuropsychological Evaluations: 10 CE
credit hours
The selection, administration and integration of
neuropsychological data into a comprehensive report.
Psy #3 - Custody Evaluations: 10 CE credit
hours
A complete course on the conducting and writing of
custody evaluations for the practicing psychologist.
Psy #4 - Forensic Evaluations: 10 CE credit
hours
This course will take you through the differing forms
of forensic evaluations and discuss the formation of a
comprehensive forensic report.
Psy #5 - Treating Childhood Sexual Abuse: 10
CE credit hours
This course discusses the thorough diagnosis and
treatment of children who have been sexually abused.
Psy #6 - Domestic Violence - Treatment and
Assessment: 10 CE credit hours
The assessment and treatment of domestic violence.
Discussion of group and individual treatment is
included.
Psy #7 - Ethics & Risk Management: 10 CE
credit hours
This course qualifies for an additional 10% discount
from NAPPP’s preferred malpractice insurer. This
is a program that discusses the newest issues facing
Psychologists ethically. A thorough discussion of
prescription privileges and pharmacopsychology ethics
is included.
Psy #8 - Mood Disorders: 10 CE credit hours
A review of the diagnosis of the spectrum of mood
disorders along with a discussion of the psychological
and pharmacological interventions for each disorder.
Psy #9 - Physiology For Psychologists: 10 CE
credit hours
This course covers basic understanding of critical
concepts in human physiology, including being aware
of indications for referral to other health care providers
for treatment and interrelationships between organs/
systems, psychopharmacology, and psychopathology.
Psy #10 - Issues In Postpartum Disorders: 10
CE credit hours
A review of the evaluation and diagnosis of postpartum
disorders. A review of the relevant literature is included.
Psy #11 - Doing Pre-Marital Counseling: 10 CE
credit hours
Dr. Sandra Levy Ceren details how to do pre-marital
counseling. This course is built upon Dr. Ceren’s many
years of experience and is replete with case studies.
Psy #12 - Mastering Medical Terminology For
Psychologists: 10 CE credit hours
This course is designed for Psychologists who want
to learn and master medical terminology. This course
will allow clinician’s to communicate effectively with
medical practitioners. A must for clinicians who
regularly work with medical practitioners.
Psy #13 - Caring For The Elderly: 10 CE credit
hours
This course is a basic course designed for Psychologists
who want to learn additional skills related to
diagnosing and treating the elderly patient. Particular
attention is devoted to dementias.
Psy #14 - Diagnosing and Treating Substance
Abuse: 10 CE credit hours
A basic understanding of diagnosing and treating
patients with substance abuse problems. The course
focuses on alcohol abuse but does cover the abuse of
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
43
Current CE courses
This 4 unit course is for those Psychologists who do not
require the more extensive 10 unit course.
This course presents a thorough presentation of the
new healthcare reform laws and how both patients
and practitioners will be affected as the new rules and
regulations are implemented. This is a must course for
those wanting to get the most out of these reforms.
Psy #16 - Introduction To Medical Psychology:
10 CE Credit hours
Psy #22 - Entrepreneurship For Psychologists:
10 CE credit hours
A basic course in medical psychology for Psychologists.
Reading materials focus on the understanding and
treatment of diseases and illnesses that Psychologists
can treat.
An introductory course for Psychologists who want to
expand their knowledge about the opportunities and
benefits of becoming an entrepreneur in mental health.
With the new Affordable Care Act now law, there are
many opportunities for Psychologists if we can learn
the concepts and success behind entrepreneurship. This
is what has been missing from graduate psychology
education.
other substances including prescription drugs.
Psy #15 - Ethics II: 4 CE Credit hours
Psy #17 - Primary Care Psychology: 15 CE Credit
hours
An introduction to how clinical psychology is practiced
in a primary care setting. Reasons for integrating
psychology into primary care are discussed along with
treatment models and the different aspects of practice
in a primary care setting.
Psy #18 - Forensic Practice: 15 CE Credit hours
An introduction to the practice of forensic psychology
for Psychologists who want to expand their services
into this area of practice. Topics include psychological
evaluations for the court (child custody; competency;
insanity), psychological factors in eyewitness testimony,
trial consultation, and criminal investigation.
Psy #23 - Crisis Management Intervention
Consulting: 15 CE credit hours
This course is designed for clinical Psychologists who
want to develop a significant and workable knowledge
base to provide crisis management consulting services
to municipalities and private organizations. It will also
serve the function of providing practitioners with a good
knowledge base to understanding crisis management
interventions.
Basic Neuropsychology (10 Contact Hours)
Ethically and legally, supervisors are responsible for
patient care as well as the training and development
of their supervisees. Supervision becomes a balancing
act between the needs of the patient population and
the needs of the supervisee. This course will help you
do your job better and give you skills to rely on in your
supervision of interns.
This course is designed to introduce clinical
psychologists to basic neuropsychological evaluation. It
provides participants with a substantive understanding
what constitutes a neuropsychological workup.
Psychologists who complete this course will learn how
to identify important neuropsychological disorders
and how to evaluate dysfunction. This course is an
introduction to what neuropsychology is but it is
not intended to convey or imply certification as a
neuropsychologist.
Psy # 20 - Neurology For Psychologists: 15 CE
Credit hours
Interpreting Blood Panels For Psychologists (6
contact Hours)
An introduction to basic neurological practice for
Psychologists. It provides participants with a thorough
understanding of the structure of the nervous system.
Topics include: performing a competent neurological
work-up, basic description and components of typical
neurological disorders, behavioral neurology, muscle
disorders, sensory disorders, and ethical issues in
practice.
Having an understanding about these tests and what
they mean is essential to all healthcare providers. This
course is designed to provide psychologists with general
information to assist in their practices and professional
development. The information provided in this course
is based on research and consultation with medical and
other authorities, and is, to the best of our knowledge,
current and accurate. .
Psy # 19 - Clinical Supervision: 6 CE Credit
hours
Psy #21 - Understanding The Affordable Care
Act: 15 CE Credit hours
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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HOW TO WRITE A BRILLIANT SUBMISSION
by David Reinhardt, Ph.D. and Elle Walker, Psy.D.
There is a famous proverb, “He who fails to plan, plans
to fail.” It’s easy to notice when a submission (even
with the best intentions) has not been planned well or
organized. An organized and structured writing piece
shows our readers (and editors!) that your arguments
are clear, concise and coherent. Hopefully with careful
planning and the application of the following tips, a
great submission will not be far behind!
Please keep in mind that The Clinical
Practitioner is the public face of NAPPP.
Internal discussions, squabbles, rants and raves,
politics and so on are best submitted to the members’
listserv. Although we entertain political discussions
within our ranks only official policy positions will
appear in TCP.
business of practice, interesting solutions to patient
problems, and other practice related topics.
1. Please make submissions @50-150 words.
2. The editors will select submissions based on
relevance and space needs.
Submissions for feature articles
We will consider feature articles of any length dealing
with practice issues, “How To” articles, and any topic
directly relating to practice. Please submit your article
ideas to [email protected]
1. A brief statement of topic and short outline of
your proposal will allow us to guide you on article
development.
We Welcome Member Submissions!
NAPPP is a practice organization. Please keep all
submissions to practice issues.
2. Articles can be any length. Please have your
editor check that every sentence has a purpose and
appropriate structure.
All Submissions regardless of type should be proof
read, spell checked, grammar and punctuation
checked. Minor editing can be done to prepare
a submission for print; However, if more than
minor corrections are needed the submission will
unfortunately have to be returned.
3. An Introductory Paragraph introducing your subject
and main Idea of your article is a MUST.
Technical Considerations
1. Please attach submissions to your email as Word
files (.doc), unless you have checked with us about
other formats.
2. Use standard fonts. We have found Verdana and
Georgia to be the most readable in electronic format.
3. If your submission must have special characters or
fonts, please embed these in your document.
4. If your submission includes objects (pictures,
graphs, drawings, etc.) these MUST be included as
separate files.
5. Please include technical references and links as
appropriate.
Letter Submissions
We welcome short submissions which deal with issues
such as insurance and billing, reports on published
research, reports on conventions attended, the
4. Supporting Paragraphs that develop the main idea
of your topic:
-Should list the points that develop the main idea of
your article
-Please place each supporting point in its own
paragraph
-Develop each supporting point with facts, details and
examples.
5. End with a Summary Paragraph or Conclusion and
do this by:
-Restating the strongest points that support the main
idea
-Conclude by restating the main idea in different words
-Give a personal opinion or suggest a plan of action.
Keep in mind that readers will only continue as long
as they are presented with new information. Do not
rehash information or ideas, but do summarize in the
final paragraph(s).
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
45
Want to know what Medical Psychology is and how we practice?
Want to support advocacy for psychological practice and get a book in return?
If you purchase this book you can do both. All revenues from the sale of this book
goes to our PsychAdvocacy Fund to help us deliver the message that doctoral level
psychological services are valued and needed. We cannot do this without your
support.
Book Description
In 2009, over fifty-two million prescriptions for antipsychotic medications were written,
totaling over $14.6 billion in sales. Such is just one small indication of how our current
medical system treats its patients with medication as a first-line approach. This is not the
answer. There is a growing need for integrated health care systems which include
psychological care, particularly those services provided by medical psychologists.
Medical psychologists are not physicians, but they do many of the same things that
physicians do or should be doing. Medical psychologists are also doing things that
clinical psychologists have never done. A medical system which profits from and relies
primarily upon medication is not sustainable, especially when these medication-only
treatments may be at the least ineffective and, at worst, harmful to patients.
This reader seeks to define medical psychology's place in this complex and
challenging environment.
To purchase the book, click here:
http://www.nappp.org/book.html
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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The Automated Medical Assistant™ was created by Dr. Gary Traub, a psychologist with
FICPP, FSMI, and FPICPP diplomates, with over 20 years of practice management and software
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A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
49
Not getting expected outcomes?
Psychotherapy can work wonders, developing coping strategies and dealing
with behaviors and mood issues. If your interventions don’t seem to “stick”
or show adequate progress, a physical problem could be at fault.
Sadness, anxiety, hyperactivity and even delusions may be worsened by a
wide range of physical issues including endocrine issues, infections, allergies,
nutritional deficiencies, environmental pollutants, and lifestyle choices.
Physicians often are poorly equipped to work with mental health
referrals. All of us hope that screening by a physician or psychiatrist would
uncover such issues. We are often disappointed to find out too little has
been done. Rather than doing an adequate assessment, psychotropics are
handed out as the solution.
Psychotropics will not fix an underlying physical problem!
Center for Health Science offers a science-based approach to uncovering and
treating the physical contributors to mental health symptoms:
 Guidance in selecting appropriate medical tests based on your patients’
symptoms
 Low cost, discount lab testing performed by major national laboratories
 Nutritional guidance
 Traditional and Functional Medicine approaches to treatment
For more information and to view CHS Solutions,
click on the link or scan the QR image below:
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A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
51
Cummings Foundation Offers Free Book
TO TCP Readers
This book is a must read for anyone who wants to understand the value of psychotherapy as a first
line treatment in behavioral healthcare. The editors have assembled an internationally known
group of experts in the field and the Cummings Foundation is making copies of the book FREE of
charge of all remaining copies to anyone who wants one. A $40.00 value for the cost of $5.00
shipping charge. If you would like your free copy of the book, email Linda Goddard at
[email protected] and she will arrange to have the book sent to you. A faster way to get your
copy is to send a check for $5.00 to
Linda Goddard
Cummings Foundation For Behavioral Health
4781 Caughlin Parkway
Reno, NV 89519
http://www.abbhp.org/
A Board Certification for Clinical Psychologists
ABBHP diplomate status in behavioral healthcare practice recognizes a set of specialty skills within general healthcare. The
diplomate recognizes experience and skills in working with behavioral health problems in ways that are coordinated with
allopathic medicine. The Specialty of Behavioral Healthcare Practice integrates behavioral health into medical care in diagnosing,
treating and providing the necessary monitoring of post-treatment behavioral follow up care.
Board certification by ABBHP is an indication to both patients and providers that you are a specialist in providing behavioral
healthcare diagnoses and treatments. Our board certification, the first of its kind, tells the public and your referral sources that you
are a specialist and partner in the primary care of patients.
Requirements
The ABBHP board certification is not a vanity board. It was designed by an experienced and influential board to be rigorous
and to ensure the public, healthcare providers and the healthcare industry that those who possess this diplomate have achieved
a high level of training and experience in providing behavioral healthcare services. Those possessing ABBHP certification are
making a statement that they are behavioral healthcare practitioners who work and belong in the healthcare industry. ABBHP
diplomates are doctoral level Psychologists who provide much more than psychotherapy services but can provide a wide range of
interventions that only a doctoral level Psychologists can. For information on qualifying for board certification, please go to
http://www.abbhp.org/
Summary of Requirements
Current and valid license to practice psychology.
Successfully pass an examination.
Complete specific coursework.
Provide a product sample.
Provide letters of recommendation
Board of Directors
Nicholas Cummings, Ph.D.
Elle C. Walker, Ph.D.
Jerry Morris, Psy.D.
Joseph Casciani, Ph.D.
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
55
The National Institute of Behavioral
Health Quality
The accreditation process for professionals and service providers engaged in behavioral
healthcare is sorely lacking and mostly absent. Consequentially, consumers and professionals
alike, have little idea or notion of what constitutes quality practice, services, and products.
The mission of NIBHQ is to provide accreditation to licensed, doctoral level behavioral
healthcare professionals and service providers. NIBHQ is a profession specific agency that
awards accreditation based on standards developed by behavioral healthcare professionals.
Our mission is to award accreditation only to those individuals and entities that can meet and
maintain adherence to standards specifically developed to promote quality in the provision of
behavioral healthcare services and products.
Do You Want To Distinguish And Promote Your Practice?
Then NIBHQ accreditation is your best way to do this. We offer a unique accreditation that
demonstrates your practice has met a high standard and is committed to quality care and
services that patients, insurers, and other healthcare professionals can rely on. See our
requirements at http://www.nibhq.org/
Continuing Education ProvidersAre you a current continuing education provider or want to be one? Then NIBHQ accreditation
of your organization will attract behavioral healthcare professionals to your courses.
Our requirements for CE providers can be obtained at
http://www.nibhq.org/
NIBHQ
A Professional Association Representing the Interests of Psychology Doctors in the Health Care System
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