Computerized Brain Training Can Produce Functional Changes in Schizophrenia

An article posted online on October 31st by Psychiatric News:

Successful training of the brains of people with schizophrenia in discrete attentional tasks is possible and appears to translate into improvements in quality of living, said Sophia Vinogradov, M.D., winner of APA’s Alexander Gralnick Award (pictured with past APA President and current APA American Psychiatric Foundation Treasurer Richard Harding, M.D.) At APA's Institute on Psychiatric Services in San Francisco, Vinogradov described research showing that computerized games aimed at training the brains of patients in very specific tasks can have effects on multiple interactive systems resulting in changes in global functioning. The finding marks a new direction in what has been called “cognitive remediation.” Further coverage of Vinogradov’s remarks will appear in a future issue of Psychiatric News. For further information about cognitive remediation, see "Neurocognitive ‘Training’ May Undo Schizophrenia's Brain Damage" and American Psychiatric Publishing's Essentials of Schizophrenia by Jeffrey Lieberman, M.D.

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Oldham Stresses Importance of Integrated Care

An article published in the June 17th edition of Psychiatric News:

By Mark Moran

John Oldham, M.D., reminds APA members and other annual meeting attendees to see the “person behind the disorder” who can be a partner in integrated care.

To incoming APA President John Oldham, M.D. [pictured], “Integrated Care”—the theme of his presidential year—is no empty catch phrase.

“To me, integrated care has many important meanings—integrating work with the rest of medicine, integrating education and teaching and the latest research findings into our clinical work, and integrating the stages of a patient's treatment into a coherent, progressive plan,” he said at the Opening Session of this year's annual meeting in Honolulu last month.

Oldham outlined four priorities that he said will guide his presidential year: integration of psychiatry with the rest of medicine, the right of patients to quality treatment, the unacceptability of fragmented care, and the importance of research and education (see New APA President's Four Focus Areas). He related a remarkable clinical vignette to remind psychiatrists of the timeless importance of seeing “the person behind the disorder,” a person who can be a partner in integrated treatment.

As an example, Oldham noted that he had recently received an e-mail from a patient (“Mr. R”) whom Oldham had treated when he was a resident at Columbia. In the e-mail, Mr. R—who had been 22 years old and a student at the time of his illness—told Oldham that “he had done OK in life, which he thought would surprise me.”

Oldham added, “He remembered me as arrogant, distant, pessimistic about his future, and not very helpful. I was stunned, since he was one of those patients we can all recall from our training years who had made a profound impression on me and was indelibly fixed in my memory.”

Mr. R, an Orthodox Jew, had fallen in love with a woman outside of the Jewish faith, and his father had told him that if he married her, it would be “the death of him.” But the young man persisted in his love and married her—and on the wedding day, the father died of a heart attack.

“I first met Mr. R shortly thereafter, when he was hospitalized in an acute psychotic state,” Oldham recalled. “What I remember from those days was how concerned I was for Mr. R—I was, after all, a student too at the time. I didn't know enough yet to appreciate the power of human resilience and the recovery potential within us all. What Mr. R saw as coldness or arrogance was, in hindsight, a defensive formality that I needed to hide my anxiety and uncertainty about how I could help him. What I also had trouble seeing at the time was the person behind the psychosis, though he was there watching me and wanting to connect with me all the time.”

After mulling over Mr. R's recent e-mail, Oldham decided to respond. “I told him that his message was valuable to me. I apologized for having been so unavailable to him, and I wished him well. A few days later he e-mailed me again saying how pleased he was that I had replied, and not to worry, that ‘all was forgiven.’ I haven't heard from him since.

“I think it conveys important messages for us all, reminding us of the power of hope, the potential for recovery, and that we must never lose sight of the whole person, who, for the time being, is not only our patient but also our partner in the treatment enterprise.”

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Dual diagnosis: Why treat one and not the other?

An article published in today's edition of The Chronicle Herald:

By Christine Stapleton [pictured]

I HOPE we can put an end to the pesky debate about alcoholism.

Alcoholism is an illness — a real illness. The American Medical Association accepted alcoholism as an illness in 1957 and for about as long the American Psychiatric Association has included alcoholism in its Diagnostic and Statistical Manual — the Bible for diagnosing mental disorders.

Alcoholism and drug addiction are more than just a lack of self-restraint and discipline. Just ask anyone who knows me. I have run marathons and countless triathlons. I have held the same job for 23 years, and I contribute to my company pension plan. I have resisted doughnut-day-Friday and the lure of expensive high-heeled, pointy-toed shoes, which certainly would have improved my love life.

I am not an aberration. In fact, many, many alcoholics are like me. We are high-functioning alcoholics who managed to hang on to our careers, cars and homes. We did not live under bridges and we did not panhandle.

Why is this important? Because I believe that dual-diagnosis is the biggest mental health problem today, yet most people do not even know what it is. Dual diagnosis is the coupling of substance abuse with another mental illness. I am talking about people like me who have alcoholism and depression or are addicted to crack and have bipolar disorder.

As I see it, the problem is that we — including the medical community and criminal justice system — do not accept and treat alcoholism as a real illness. Nor do they understand and appreciate how futile it is to treat one illness but not the other. Everyday addicts and alcoholics seek treatment for substance abuse but no one bothers to screen them for a companion mental illness. Likewise, doctors prescribe antidepressants to their patients without screening them for substance abuse.

The addict/alcoholic whose depression is not treated will continue to self-medicate with drugs and alcohol or fail at the attempt to get clean and sober. Those with depression whose substance abuse is not detected will get sicker because alcohol is a depressant and with every sip they are throwing gasoline on their simmering depression or bipolar.

No one knows how many dual-diagnosed alcoholics/addicts are out there but experts believe at least one of every three alcoholics/addicts has another mental illness. They are the most tragic and costliest of the mentally ill. Very often they commit crimes or suicide. They abuse their wives/husbands and children. Police answer their 911 calls and foster parents take in their kids. The dual diagnosed often become homeless and clog our emergency rooms.

So if you want to go on believing that addicts and alcoholics are weak-willed and you have no compassion for them, please have mercy on your wallet. Your ignorance is costing all of us.

Christine Stapleton writes for The Palm Beach Post, West Palm Beach, Fla.

I have changed the headline of this story to the one that appeared in the The Palm Beach Post.

Also see:

Schizophrenia and Substance Use

Concurrent Disorder

Landmark Institute of Medicine Report Paves Road to Prevention

An article published in the April 3rd edition of Psychiatric News:

By Mark Moran

American Psychiatric Association (APA) leaders involved with the report say it points to a "paradigm shift" in the way medicine and psychiatry approach mental health and illness in the future.

Prevention of mental illness and promotion of mental health are scientifically feasible, and the time is ripe to transfer the science into practice.

That is the conclusion of a landmark report by the Institute of Medicine (IOM) titled "Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities."

Prevention practices have emerged in a variety of settings, including programs for selected at-risk populations—such as children and youth in the child-welfare system—school-based interventions, interventions in primary care settings, and community services designed to address a broad array of mental health needs and populations, according to the report.

The report updates a 1994 IOM book, Reducing Risks for Mental Disorders, and focuses attention on the research base and program experience with younger populations that have emerged since that time.

The book-length report includes chapters on (among other subjects) using a developmental framework to guide prevention and promotion; perspectives from developmental neuroscience; preventive intervention research—including family, school, and community interventions; prevention of specific disorders; screening; benefits and costs of prevention; and implementation and dissemination of prevention and promotion practices.

APA leaders are hailing the report saying it points to a paradigm shift in the way psychiatry approaches mental illness in the future.

"Both prevention and psychiatry have always been the stepchildren of medicine," said APA President Nada Stotland, M.D. "It is not as glamorous as open-heart surgery or restoring a brilliant individual with bipolar disorder to her career and family. It is much easier to get credit for fixing something that is broken than for keeping it from breaking in the first place. However, most of the improvements in life span are the result of preventive, rather than treatment, measures—immunizations, pap smears, clean air and water, smoking cessation.

"Most health professionals are unaware of the crucial data in the IOM report," Stotland said. "Now that it has been published, and we know that there are effective ways to prevent psychiatric disorders in children, there is no excuse for our country's continued failure to implement the policies that would protect our children from lifetimes of suffering and disability."

Child psychiatrist William Beardslee, M.D., a member of the IOM committee and chair of APA's Corresponding Committee on Prevention of Mental Disorders and Promotion of Mental Health, echoed Stotland.

"This is a landmark report and deserves to be read with care by every psychiatrist," Beardslee told Psychiatric News. "Psychiatry has an opportunity to provide extraordinary leadership in the prevention of mental illness, and we strongly urge APA and individual psychiatrists to support the report's recommendations."

Those recommendations include a call for a coordinated national strategy originating in the White House for implementing prevention and promotion practices.

The IOM report stated, "The White House should create an ongoing mechanism involving federal agencies, stakeholders (including professional associations), and key researchers to develop and implement a strategic approach to the promotion of mental, emotional, and behavioral health and the prevention of mental, emotional, and behavior disorders and related problem behaviors in young people."

Psychiatrist Carl Bell, M.D., also a member of the IOM committee, said that recommendation was modeled on the success of a similar White House cabinet-level strategy during the Clinton administration concerning violence against women.

"What the IOM is saying is that it is possible to prevent psychiatric disorders, substance abuse, and problem behaviors," Bell told Psychiatric News. "The challenge for psychiatry is to shift its paradigm and stop thinking of itself as a field that only treats the sick, but begins to think in terms of a public-health model."

Beardslee and Bell both stressed that the IOM report underscores the importance—and scientific basis—not only of preventing or preempting the occurrence of major mental disorders among individuals who exhibit preclinical symptoms, but also broad population-based strategies aimed at promoting mental health.

Beardslee stressed as well that in the background of all behavioral disorders are the issues of poverty and health disparities.

"Prevention should be a part of regular psychiatric practice," Beardslee said. "I see three levels at which psychiatrists can be putting prevention into practice. As social scientists, we should be embracing the public-health perspective and broad reforms to address health disparities and poverty. A second level where psychiatrists can have a very large impact is in working with adults with mental illness who have children, doing preventive work using psychoeducational models.

"And the third level is the use of preventive strategies that have been designed for people at very high risk."

APA Helps Psychiatrists Improve Patient Safety

From the January 16th edition of Psychiatric News:

By Aaron Levin

A new APA [American Psychiatric Association] publication helps psychiatrists reduce errors and keep patients safer.

Patient safety rose in prominence in American medical thinking with the publication a decade ago of "To Err Is Human," the Institute of Medicine's (IOM) report estimating that tens of thousands of people die every year in American hospitals due to preventable medical errors.

Now APA has published a 33-page handbook that addresses ways to develop and integrate systems to reduce or prevent six critical events: suicide, aggression, falls, elopement, medical comorbidities, and drug or medication errors. Each chapter provides examples of unsafe care along with discussions of what went wrong and how to prevent mistakes.

To read the entire article, click here.

Click on the image to enlarge it.

To download SAFE MD, the 33-page handbook, click here (PDF).

SAFE MD: Practical Applications and Approaches to Safe Psychiatric Practice

Resource document, approved by the Joint Reference Committee in June 2008, that emphasizes applications and approaches to safe psychiatric practice in six categories: Suicide; Aggression; Falls; Elopement; Medical comorbidity; and Drug/medication errors.