APA Practice Guideline Research Articles

Response to Marcus et al. Letter

Back to table of contents Previous article Next article Communications and UpdatesFull AccessResponse to Marcus et al. LetterJoel Yager, M.D., Alan J. Gelenberg, M.D., and Laura J. Fochtmann, M.D.Joel YagerChair, APA Steering Committee on Practice Guidelines Denver, Colo.Search for more papers by this author, M.D., Alan J. GelenbergChair, APA Work Group on Major Depressive Disorder Hershey, Pa.Search for more papers by this author, M.D., and Laura J. FochtmannMedical Editor, APA Practice Guidelines Stony Brook, N.Y.Search for more papers by this author, M.D.Published Online:1 Feb 2011https://doi.org/10.1176/appi.ajp.2010.10101515rAboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: We thank Dr. Marcus et al. for bringing this error to our attention. The upper dose of aripiprazole studied for adjunctive treatment of major depressive disorder is 20 mg/day, and the upper recommended dose is 15 mg/day. A correction will be made in the guideline text published on PsychiatryOnline.com.Chair, APA Steering Committee on Practice Guidelines Denver, Colo.Chair, APA Work Group on Major Depressive Disorder Hershey, Pa.Medical Editor, APA Practice Guidelines Stony Brook, N.Y.The authors' disclosures accompany the APA Practice Guideline.accepted for publication in December 2010. FiguresReferencesCited byDetailsCited ByNone Volume 168Issue 2 February 2011Pages 211-211 Metrics PDF download History Accepted 1 December 2010 Published online 1 February 2011 Published in print 1 February 2011

AMA Backs 'Medical Home' Despite Specialists' Concerns

AMA Backs 'Medical Home' Despite Specialists' Concerns

Trustees Tackle Wide Range of Controversial Issues

Trustees Tackle Wide Range of Controversial Issues

Anorexia Nervosa

Anorexia Nervosa

Understanding and Preventing Criminal Recidivism Among Adults With Psychotic Disorders

Understanding and Preventing Criminal Recidivism Among Adults With Psychotic Disorders

Don't Miss APA Practice Guidelines, Watches, and Drafts

Don't Miss APA Practice Guidelines, Watches, and Drafts

Under‐recruitment of patients for clinical trials: an illustrative example of a failed study

Under‐recruitment of patients for clinical trials: an illustrative example of a failed study

Guideline Watch (April 2007): Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition

Since the publication in May 2006 of APA's Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition (1), results have been reported for a multisite randomized, controlled trial evaluating the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence in nonspecialty treatment settings (the COMBINE study, 2). In addition, two novel pharmacotherapies have been approved for use in the treatment of nicotine dependence (varenicline) and alcohol dependence (intramuscular naltrexone). This watch describes these developments. (Reprinted with permission from the American Psychiatric Association: April 2007)

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

Changes in the Quality of Care for Bipolar I Disorder During the 1990s

We Need to Pay More Heed to Eating Disorders

Back to table of contents Previous article Next article ViewpointsFull AccessWe Need to Pay More Heed to Eating DisordersDenise Senyk, M.D.Denise SenykSearch for more papers by this author, M.D.Published Online:18 Aug 2006https://doi.org/10.1176/pn.41.16.0018aI have noticed that over the past five years in my practice, I am seeing increasing numbers of patients who suffer from eating disorders, often comorbid with other serious psychiatric illness.For most psychiatrists, unless they have chosen a specialty elective in this field, residency training addressing anorexia nervosa, bulimia nervosa, binge-eating disorder, or the nebulous eating disorder NOS is relatively spare. Though there are opportunities for postresidency training in the field of eating disorders, since formal ABPN certification does not exist as it does for geriatric or forensic specialization, for example, there are few fellowships available.This is not surprising given the small number of DSM-IV-TR diagnoses available to psychiatrists in this category.The new APA Practice Guideline for the Treatment of Patients With Eating Disorders, Third Edition, was released in July. It highlights the potential leadership role for psychiatrists “within a program or team that includes other physicians, psychologists, registered dietitians, and social workers.”If the standing-room only crowd at Dr. Joel Yager's “Focus Live” session on eating disorders at this year's APA annual meeting in Toronto is any indication, I would deduce that many of my colleagues are already being called upon or are ready to offer leadership and expertise in this field. Yager chaired the work group that developed the eating disorders practice guideline.Like many of us outside of academia, I practice in a variety of settings (outpatient, inpatient, residential). In the residential treatment setting for serious and persistent mental illness, I have discovered that close to 25 percent of my patients have a comorbid eating disorder, often with a complex presentation. For example, a woman with schizoaffective disorder, anorexia nervosa, and borderline personality disorder stopped purging, but proceeded to cut her abdomen in an attempt to “cut the ugly fat out” of her body.In an article in May/June issue of Psychosomatic Medicine, Dr. Barton Blinder, founder and chair of the APA Caucus of Psychiatrists Treating Patients With Eating Disorders, reported that 97 percent of patients at an inpatient eating-disorders program had a comorbid Axis I diagnosis. In this sample there were more diagnoses of psychosis in patients with anorexia than those with bulimia.Beyond the traditional eating-disorder diagnoses, we now have the epidemic of obesity with which to contend. The advent of second-generation antipsychotics has added not only an effective addition to our pharmacologic tool chest for both psychotic and bipolar spectrum disorders, but also an additional responsibility to monitor our patients for metabolic syndrome. This increased monitoring of our patients' weights, BMI, lipids, and glucose tolerance is helping us to identify and manage weight-related pathology more effectively. In fact, many, including Dr. Renu Kotwal, believe that obesity should be considered a psychiatric disorder. He found that 87.2 percent of bipolar patients treated at a weight-management program had an eating disorder, compared with 71.3 percent of patients without bipolar disorder. The relationship between obesity, binge-eating disorder, and severe and persistent mental illness is fertile ground for new research.There are several excellent professional organizations that focus on eating disorders; however, they are primarily for either researchers or are interdisciplinary in nature. As the leaders of eating-disorder treatment teams, it is imperative that, as psychiatrists, we continue to organize around the issues of residency and fellowship training in this important area, encouraging and supporting psychiatrists in eating disorders research, access to care, diagnostic and treatment advances, clinical excellence, and advocacy for our patients.The APA Caucus of Psychiatrists Treating Patients With Eating Disorders will meet at the 2006 Institute of Psychiatric Services on Saturday, October 7, from 1:30 p.m. to 3 p.m. in the Jolson Room on the ninth floor of the Marriott Marquis. Please join us. ▪Denise Senyk, M.D., is in private practice in Bucks County, Pa., and medical director of Project Transition. ISSUES NewArchived

Application of The APA Practice Guidelines on Suicide to Clinical Practice

This article presents charts from The American Psychiatric Association Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors, part of the Practice Guidelines for the Treatment of Psychiatric Disorders Compendium, and a summary of the assessment information in a format that can be used in routine clinical practice. Four steps in the assessment process are presented: the use of a thorough psychiatric examination to obtain information about the patient's current presentation, history, diagnosis, and to recognize suicide risk factors therein; the necessity of asking very specific questions about suicidal ideation, intent, plans, and attempts; the process of making an estimation of the patient's level of suicide risk is explained; and the use of modifiable risk and protective factors as the basis for treatment planning is demonstrated. Case reports are used to clarify use of each step in this process.

Economic Incentives Increase Access to Depression Care

Back to table of contents Previous article Next article From the PresidentFull AccessEconomic Incentives Increase Access to Depression CareSteven Sharfstein, M.D.Steven SharfsteinSearch for more papers by this author, M.D.Published Online:6 Jan 2006https://doi.org/10.1176/pn.41.1.0003Employer-based health insurance is the major means by which we pay for health care in America.For years APA has been a leader, through its Business Initiative and the American Psychiatric Foundation's Partnership for Workplace Mental Health, in working with employers to alert them to the morbidity associated with untreated mental illness in the workplace, particularly depression.The economic losses associated with absenteeism and with reduced productivity of depressed employees have led many employers to advocate for better insurance coverage and incentives for the treatment of depression. Based in part on pressure from employers, the Aetna Company, one of the world's largest insurance companies, has decided to pay increased fees for primary care physicians to screen patients for depression and to provide follow-up care for patients who are then started on anti-depressant medications.In this program, severely depressed patients may be referred by the primary care physician to a psychiatrist for care. The depression screening involves a written test and the Patient Health Questionnaire (PHQ-9), which was developed at Columbia University and tested in a variety of settings. Physicians participating in the Aetna program are in six states and will be paid 30 percent to 40 percent more for a routine visit when the depression screening questionnaire is used.Since family physicians and other primary care doctors write an estimated two-thirds of prescriptions for antidepressants in the United States and are often the gate-keepers for referral to psychiatrists and mental health professionals, this Aetna program, which will be carefully evaluated, is an important breakthrough in providing financial support for depression treatment. With nearly half of lost productivity in the United States attributed to major depression, with an estimated cost of $44 billion annually, this Aetna program will be carefully reviewed by other major payers, HMOs, and employer groups, as well as professional organizations such as APA. (To learn more about how APA is working to improve quality by working with the business community, see Viewpoints column by Norman Clemens, M.D., on Original article: page 20).Of course, any such study of treatment costs or savings cannot lose sight of the key concern, which is making sure that each patient gets the depression treatment that is best for him or her. Antidepressants are often seen as the first-line treatment, as they are in the Aetna program. However, many well-designed studies show that psychotherapy, especially cognitive-behavioral therapy, is also beneficial for patients with depression and that cognitive therapy is as effective as antidepressant medication for milder depression. A study by Robert DeRubeis, Ph.D., and colleagues in the April 4, 2005, Archives of General Psychiatry showed that cognitive therapy can be as effective as medication for initial treatment of moderate to severe depression, although cognitive therapy requires a high level of therapist expertise.The APA practice guideline for treatment of depression emphasizes that the choice of treatment depends on patient preference and the specialized skills of clinicians. The presence of significant psychosocial stressors, intrapsychic conflict, interpersonal difficulties, or comorbid Axis II conditions indicate a need for psychotherapy as well as medication treatment.Why are economic incentives encouraging depression treatment so important? We know that, depending on the study, only between 5 percent and 40 percent of depressed patients seen in primary care receive appropriate treatment and follow-up. In the U.S. comorbidity study, only one-third of people with depression received any care at all. According to burden-of-illness studies, by 2020 depression will be the leading cause of disability worldwide.APA is working to improve the quality of depression treatment across health care settings through projects such as the National Depression Management Leadership Initiative of the American Psychiatric Institute for Research and Education—a collaboration between APA, the American Academy of Family Physicians, and the American College of Physicians—to increase the availability and quality of depression care through standardized use of the PHQ-9 (Psychiatric News, June 3, 2005).Other efforts include the APA Business Initiative's partnership with the Kansas City employer coalition on the Community Initiative on Depression, which leveraged the business community to address care for depression delivered not only in primary care settings, but oncology and cardiology as well (Psychiatric News, May 6, 2005).The Aetna program is a leader in turning a spotlight on effective and early diagnosis and treatment for this major medical/psychiatric condition. You can be sure that APA will study the results of this initiative with great interest. ▪ ISSUES NewArchived

Cultural Formulation: From the APA Practice Guideline for the Psychiatric Evaluation of Adults, 2nd Edition

Cultural Formulation: From the APA Practice Guideline for the Psychiatric Evaluation of Adults, 2nd Edition

APPI Books Address Wide Range Of Member Interests

Back to table of contents Previous article Next article The Medical Director's DeskFull AccessAPPI Books Address Wide Range Of Member InterestsJames H. Scully Jr., M.D.James H. Scully Jr.Search for more papers by this author, M.D.Published Online:16 Sep 2005https://doi.org/10.1176/pn.40.18.00400004 APA's publishing arm, American Psychiatric Publishing Inc. (APPI), had another banner year in 2004. Under the leadership of CEO Ron McMillen and Editor in Chief Robert Hales, M.D., APPI's success is attributable to producing a wide variety of high-quality publications to serve the diverse information needs of APA members and nonmember mental health professionals.With 750 books in print, seven journals, a new Web portal at<PsychiatryOnline.com>, and more than 40 new titles each year, APPI's status as the leading publisher in psychiatry is well known in the publishing and mental health communities.APPI's mission is to publish authoritative, up-to-date, and affordable books for psychiatrists, trainees, policymakers, and mental health and other health care professionals.As a niche publisher, APPI focuses its acquisition efforts, manufacturing expenses, and marketing resources on the relatively small, well-defined psychiatry market and thus is able to compete effectively with larger publishers that are required to cover wider fields of interest.However, within the psychiatry market, APPI focuses on the needs of a diverse group of academic, research, and clinical psychiatrists with a variety of interests and information needs.Books and electronic publications are acquired with two main considerations in mind: subject area and end-use context.The subject areas include everything from in-depth discussions of catatonia to comprehensive coverage of personality disorders, forensic psychiatry, and psychosomatic medicine. Psychotherapy is the focus of the largest category of APPI books.End-use contexts include formats such as textbooks, professional texts, clinical manuals, concise guides, e-books, and PsychiatryOnline, where APPI books and journals come together in a powerful online reference. Each new project is undertaken within the larger context of subject category, end-use context, and editorial calendar.At any given time, APPI may have 80 books in development. Such aggressive acquisition efforts have led to a 2005 list that includes an impressive array of new books, including a focus on comprehensive textbooks that serve as primary information references. Textbooks on APPI's 2005 list include American Psychiatric Publishing Textbook of Psychosomatic Medicine, American Psychiatric Publishing Textbook of Personality Disorders, Psychodynamic Psychiatry in Clinical Practice, 4th Edition, American Psychiatric Publishing Textbook of Psychoanalysis, and American Psychiatric Publishing Textbook of Mood Disorders.Other books on the 2005 list include titles on complementary and alternative medicine; issues relevant to women's mental health; manuals of geriatric, pediatric, and adult psychopharmacology; books in collaboration with patient advocacy groups; online self-assessment exams and board-preparation books; books on practicing in a correctional setting, community setting, and private practice; books on education, research, and career development; books for quality improvement in practice; and a popular new series on core competencies in psychotherapy, edited by Glen Gabbard, M.D.Developing new products in the face of changing technologies and increasing competition led to a new APPI electronic publishing initiative in March—PsychiatryOnline, which provides access to APPI references for patient diagnosis, treatment, professional development, and lifelong learning. The site's integrated full-text resources include DSM-IV-TR, APA's practice guidelines, American Journal of Psychiatry and four other psychiatry journals, American Psychiatric Publishing Textbook of Clinical Psychiatry, and self-assessment tools for board certification, recertification, and CME.The site, at<PsychiatryOnline.com>, features a powerful search engine that allows search refinement by books versus journals, title, and increasingly specific subtopics, speeding users to exactly what they're looking for. Related content links and hyperlinked references allow users to connect quickly from diagnosis and treatment to the latest research. The Web site's book content is completely portable, allowing users to select any section they need for instant download to their PDA.“The vital resources and services of PsychiatryOnline are accessible from wherever our customers might be—home, office, or hospital,” said Pam Harley, director of APPI's e-publishing strategy and product development. “More and more, psychiatrists need trusted answers fast and on the spot, and APPI is working hard to provide anytime, anywhere access to information.”The site is available to individuals through subscription and to institutions through site licenses. APA members receive a substantial discount on subscription rates.APPI is always on the lookout for ideas for new books and electronic products and welcomes new authors. If you have a book idea, contact Dr. Hales by e-mail at [email protected] or John McDuffie at [email protected]. More information about APPI publications is posted at<www.appi.org>.▪James H. Scully Jr., M.D., is medical director and CEO of APA. ISSUES NewArchived

Antidepressants for Bipolar Depression

Back to table of contents Previous article Next article Letter to the EditorFull AccessAntidepressants for Bipolar DepressionJEFFREY C. FETTER, M.D., and KATHLEEN D. ASKLAND, M.D., JEFFREY C. FETTERSearch for more papers by this author, M.D., and KATHLEEN D. ASKLANDSearch for more papers by this author, M.D., Lebanon, N.H.Published Online:1 Aug 2005https://doi.org/10.1176/appi.ajp.162.8.1546AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The review of antidepressants for bipolar depression by Dr. Gijsman et al. provided an excellent overview of the randomized, controlled trials in the literature. However, the presented data all reflect acute antidepressant treatment response, with the longest study duration (10 weeks). Bipolar disorder is a chronic, relapsing condition, with an etiology likely distinct from that of unipolar depressive disorder, for which current antidepressants were specifically developed. Treatment approaches applied to alleviate symptoms during acute exacerbations may have significant impact on the long-term course of the illness. The authors did not present evidence that the long-term outcomes are favorable with antidepressant treatment; thus, their conclusion to challenge the APA practice guideline for recommending lithium or lamotrigine as first-line treatment for bipolar depression is unfounded.There are long-term (of 11–24 months) prospective, placebo-controlled (1–3), naturalistic prospective (4, 5), and retrospective studies (6)—excluded categorically from the current review—showing that antidepressant exposure is associated with worse long-term outcomes in patients with bipolar disorder, apart from the concern for acute mania. Developing treatment guidelines requires an integration of all available data.The question of whether bipolar depression responds best to adding a mood stabilizer or an antidepressant may be amenable to investigation by a long-term practical clinical trial. This model of structuring studies to compare relevant alternative interventions in diverse, real-life patient populations and practice settings is gaining support from research decision makers. Current data on antidepressants in bipolar depression do not justify changing the APA treatment guidelines.

More FrequentDSMUpdates Recommended

Back to table of contents Previous article Letters to the EditorFull AccessMore Frequent DSM Updates RecommendedRoger Peele, M.D., Maryam Razavi, M.D., and Roger PeeleSearch for more papers by this author, M.D., Maryam RazaviSearch for more papers by this author, M.D., and Published Online:15 Jul 2005https://doi.org/10.1176/pn.40.14.00400029There should be a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) each year. The present DSM has diagnostic criteria last updated in the early 1990s, with text last updated in the late 1990s. The clinician turning today to the DSM-IV-TR does not know whether the conceptualization of the criteria over the past dozen years has changed and does not know the currency of the text. Examples of the need for diagnostic criteria classification are in the areas of childhood bipolar disorder and adult attention-deficit/hyperactivity disorder, where DSM-IV-TR is unenlightening. In addition, disorders have emerged and grown, such as fetal alcohol syndrome, on which the DSM-IV-TR is silent.Some say that the costs of such an endeavor would be astronomical and that to develop each new criterion set would be a million-dollar project. That is not true. APA can and should do what other medical specialties do: have the experts state where the field is today—not require the development of new science.Some say that publishing a new DSM each year would be seen as a revenue-driven initiative. That is not true. Each year the specific changes could be placed on the APA Web site for those not wanting to buy the book.APA does not plan to complete a substantial revision of the DSM until about 2012. We should not assume that the growth of knowledge in psychiatry is so minimal that we are justified in waiting until then.Rockville, Md.Washington, D.C.psychnewsPsychiatr NewsPsychiatric NewsNewspaper of the American Psychiatric AssociationPsychiatr NewsPsychiatr News0033-27041559-1255American Psychiatric AssociationLetters to the Editor - ResponseDarrel Regier, M.D., M.P.H., He is director of APA's Division of Research and executive director of the American Psychiatric Institute for Research and Education1572005The possibility of developing a process for more frequent updates of the DSM has been discussed with APA's Committee on Psychiatric Diagnosis and Assessment and the Board of Trustees on several occasions over the past two to three years. Models for such updates are the AMA's CPT procedure codes, APA's practice guidelines, and the National Center for Health Statistics' ICD-9-CM annual updates of diagnostic codes. These organizations and agencies have established a permanent infrastructure to support regular reviews of emerging medical procedures, the clinical trials and other research bases to support treatment modifications, and proposals from the scientific community for changes in diagnostic names or code numbers. However, modifications of explicit diagnostic criteria in the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR have not been made between revisions because of the absence of a credible, established scientific review structure and because of a concern that each change could have significant impacts on national and international research studies, which include the clinical trials that lend support for treatment guidelines.The Division of Research is currently reviewing the research base for modifying diagnostic concepts and criteria in DSM-V with a $1.2 million grant from the National Institutes of Health. At the same time, we are examining alternatives both for modifying the text more frequently to reflect new associated features and for considering changes in the criteria for individual disorders when substantial scientific evidence supports such changes. ▪ ISSUES NewArchived

Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

Testing an APA Practice Guideline: Symptom–Targeted Medication Utilization for Patients With Borderline Personality Disorder

Background: The goal of this study was to test whether the use of psychotropic medication treatment for borderline personality disorder (BPD) was consistent with proposals in the recently published American Psychiatric Association’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Method: Medication utilization by patients with BPD was assessed prospectively over a 2-year period prior to the publication of the Guideline. Three BPD symptom clusters—cognitive-perceptual, affective dysregulation, and impulsive-behavioral dyscontrol—along with demographic and functioning variables were used to predict the use of five classes of medication. Results: Symptoms of impulsive-behavioral dyscontrol significantly predicted use of both neuroleptics and anticonvulsants. Cognitive-perceptual symptoms were inversely related to anticonvulsant use. Conclusion: While some pre-Guideline medication practices with BPD patients were consistent with the recommended algorithms, physicians may...

APA Office Is Your Partner In Delivering Quality Care

APA Office Is Your Partner In Delivering Quality Care

Patterns and Quality of Treatment for Patients With Major Depressive Disorder in Routine Psychiatric Practice

Patterns and Quality of Treatment for Patients With Major Depressive Disorder in Routine Psychiatric Practice