INTRODUCTION
Voiceover: San Francisco opened its Golden Gate to welcome the American Psychiatric Association for its 162nd annual meeting. More than 15,000 people attended this year's sessions at the Moscone Center to learn about the latest developments in the prevention and treatment of mental health disorders.
SEGMENT 1: Conflicts of Interest
Voiceover: Among the most controversial subjects raised at this year's meeting was the potential for conflicts of interest among psychiatrists who receive research support and other financial considerations from the pharmaceutical industry.
The draft guidelines, which will be distributed to APA members for their comments, are intended to guide psychiatrists in their relationships with the pharmaceutical industry and help them avoid real and perceived conflicts of interest. Dr. Paul Appelbaum heads the workgroup that drafted the new guidelines.
Appelbaum: Insofar as the public might come to believe that physicians in general, psychiatrists in particular, have abandoned their patients' interests as their primary concern, perhaps being misled, seduced, or distracted by their relationships with for-profit pharmaceutical or device entities, we will have lost an important bond that we have with the public at large and with the people we treat, and so both from an ethical perspective and from a very practical trust-based perspective, there are strong reasons to develop recommendations at this point.
SEGMENT 2: DSM-V
Voiceover: Another topic of special interest to psychiatrists is the ongoing development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-V. The new edition will address the significant advances in understanding of the origin and treatment of mental disorders that have been made since the last DSM revision in the mid-1990s, says Dr. William Narrow, research director for the DSM-V task force.
Narrow: We definitely anticipate that the DSM-V will go beyond what DSM-IV and DSM-III gave us, which was categorical assessments with strict diagnostic criteria. We are expecting that we'll be giving clinicians and researchers the opportunity to assess their patients beyond the strict categories and to use dimensional assessments of severity of a range of different symptoms that go along with disorders. For example, assessing anxiety in major depressive disorder: currently, there is no anxiety criteria in the major depressive disorder, although we do know that anxiety and depression often travel together. They're highly comorbid.
Voiceover: Among the most hotly debated sections of the DSM are the entries on gender identity disorders, which have been criticized as stigmatizing by some members of the gay, lesbian, and transgender communities. Dr. Jack Drescher, a psychiatrist in private practice in New York City, is a member of the DSM-V work group on sexual and gender identity disorders.
Drescher: Yesterday we had a very good, interesting DSM symposium called "In or Out?" discussing the question of whether the GID diagnoses should remain in the DSM-V or should be withdrawn. We had a couple of representatives from the APA and the DSM-V workgroup who presented the process that we'd been going through in detail, and then we had 4 speakers, members of the trans community who came and spoke about their concerns and some of the issues both from a healthcare aspect, a stigma aspect, and advocacy aspect, and a policy aspect, and it felt like it was a very successful meeting, because in a sense we were all aware of the issues involved and I don't think there was any disagreement that there are some very important issues that need to be addressed. I think the only thing that we don't have yet is a good, solid working answer about how to reconcile the conflicting need between making sure that people are not stigmatized with the need for access to medical care and treatment.
SEGMENT 3: Insomnia
Voiceover: As many as 15% of Americans may suffer from insomnia, according to a study looking at National Health and Nutrition Examination Survey data. Among more than 6100 adults surveyed, 15% met DSM-IV criteria for insomnia. Of particular concern to psychiatrists was the finding that about half of all survey participants with insomnia also met DSM-IV criteria for major depressive disorder. Lead author Dr. Tuan-Anh Nguyen says that clinicians should consider underlying mental disorders when evaluating patients with insomnia.
Nguyen: For psychiatric doctors, I think the most important thing is, males, gentleman don't show up to the doctor so often for their sleep problems, but once they show up, once they have complaints, they might have big problems. So for psychiatrists we should pay more attention to the male, to the men who are coming in for sleep problems.
SEGMENT 4: Depressive Disorder and CVD
Voiceover: Long-term results from the Sertraline Antidepressant Heart Attack Randomized Trial, or SADHART, show that patients with intractable depression after a heart attack or episode of unstable angina have twice the mortality rates of similar patients who recover from depression, with the excess death rate continuing for up to 7 years after the initial cardiac event. Principal investigator Dr. Alexander Glassman says that difficult-to-treat depression appears to be an independent risk factor for death among patients who have suffered a cardiovascular event.
Glassman: Those people that got drug and looked like they were getting better when they were actively treated, that difference between drug and placebo disappeared rather quickly after treatment was stopped, and over the long term there was no advantage to acute treatment. However, those people that got better did remarkably better than the people who do didn't get better, whether they were treated with drug or placebo, so not getting better, independent of what you were treated with, essentially doubled — more than doubled — the mortality rate.
Voiceover: Dr. Glassman and colleagues also found that patients with more severe depression in the early weeks after a cardiovascular event had a nearly 3-fold greater risk for death compared with those with fewer symptoms.
Glassman: But the thing that's really startling is that it's a single measure of depression on a Hamilton scale, measured 2 or 3 weeks after a heart attack, and it's predicting whether they die over the next 7 years. If you think about how that could happen, it's hard to understand, and although we don't have proof about why it happens, our suspicion is that some of the people with heart attacks have very high levels of inflammation, and that that's associated with a cardiac disease. And like inflammation can provoke depression in people who are being treated with alfa-interferon for hepatitis C or for malignant melanomas, we're beginning to suspect that maybe people with very active vascular disease and high levels of inflammation related to that disease can also be a risk factor for depression, and that it would be the inflammation that's really predicting this very high rate of mortality over such a long period of time.
SEGMENT 5: Women Vets and Suicide Risk
Voiceover: Data from a large, population-based cross-sectional study show that women veterans are 2 to 3 times more likely than nonveteran women to commit suicide. Women veterans who commit suicide are also more likely to be young and to use firearms to kill themselves than nonveterans, who tend to use methods such as drug overdose. The study confirms results of an earlier longitudinal study indicating that women veterans had a 3-fold greater risk for suicide compared with their civilian counterparts, says study investigator Dr. Bentson McFarland.
McFarland: "An important part of our study was that we focused on all women veterans, not just veterans who'd made use of the Veterans Affairs medical care system, so we're looking at veterans in the general population. Important messages here for clinicians are that women may very well have had military experience, these women may — most likely — be getting all their healthcare outside the Veterans Affairs system. So number 1, it's important for clinicians — general practitioners, folks in primary care — to ask women patients "Have you ever served in the military?" And number 2, it's also very important to recognize that women veterans, just like men, are at elevated risk of suicide compared to nonveterans."
SEGMENT 6: Give an Hour
Voiceover: To help veterans cope with a wide range of mental health issues, the American Psychiatric Association has partnered with Give an Hour, a national nonprofit group that provides free mental health services to returning veterans and their families. Give an Hour Founder and President Dr. Barbara Van Dahlen Romberg explains the need for the services her organization provides.
Romberg: Well, as a mental health professional — I'm a clinical psychologist — I recognized about 4 years ago that even though the VA and DOD are doing more than they've ever done before to recognize the needs of our returning men and women and their families, that the need was huge and as the war has gone on it's clear we are now facing a public health crisis. There are 1.9 million men and women who have served and if you multiply that times about 10 to 15 family members for each one affected it's a huge number of people, and that resources aren't there, especially at the community level. Many people live in areas where there are no VA services, and so we needed to harness the treatment, knowledge, the good will, the compassion of the mental health community to step up and fill the gap.
SEGMENT 7: Deep-Brain Stimulation for Refractory Depression
Voiceover: Two small studies, one conducted at 3 Canadian centers and the other at the Cleveland Clinic, suggest that deep-brain stimulation can produce high response rates in patients with unipolar depression refractory to multiple previous forms of therapy, including cognitive behavioral therapy and electroconvulsive therapy. According to Canadian investigator Dr. Peter Giacobbe, the early studies suggest that deep-brain stimulation may be an acceptable therapeutic alternative for patients with difficult-to-treat depression.
Giacobbe: The good news is that those who got well early tended to stay well, so this is something that potentially can extend the algorithm for people with depression who have failed multiple treatments.
Voiceover: In the second study, Cleveland Clinic investigators saw a 70% response rate, and one third of patients were in remission at the last follow-up, at an average of 37 months.
Dr. Giacobbe says that further studies of deep-brain stimulation are needed.
Giacobbe: Although the results of this open-label study are quite provocative and suggest that the active ingredient is stimulation of the brain, we're not still quite sure that that's the case, so the next phase is to do a double-blind, placebo-controlled trial to sort out why exactly are people getting better with the treatment. Is it the stimulation? Is it some of the nonspecific effects that go with being part of the trial? And so that's what we're trying to sort out next.
SEGMENT 8: Alcoholism Isn't What It Used to Be
Voiceover: Traditional alcoholism prevention and treatment programs are based on outmoded notions of what constitutes alcoholism and may need a major overhaul, say investigators with the National Epidemiologic Study of Alcohol and Related Conditions, or NESARC. A prospective study of more than 43,000 adults in the United States shows that more than half of alcohol-dependent individuals are healthy, functional, young adults, and not the stereotypical middle-aged white male, "skid row" alcoholic, according to Dr. Mark L. Willenbring, director of the division of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism.
Willenbring: Here's really the take-home message: It's that these are not patients who are likely to enter a rehab program, because let's face it, none of us would really want to enter a rehab program if we didn't really desperately have to. These are folks who really don't have to in that sense, and yet there they are in your practice, they're in your primary care practice, they're in your psychiatric care practice, and we're not identifying them and addressing it. And it turns out that at-risk drinkers will frequently quit or cut down with some very brief motivational advice from a physician. There are also 4 medications available for treating alcohol dependence, and the mild-to-moderate dependence that is characteristic of people who are the functional alcoholics respond very well to medication and medical management.
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