Deep Brain Stimulation for Alzheimer’s Disease

Posted on June 10, 2013 by rkennedy

Investigators from Brown University and two Rhode Island hospitals are participating a clinical trial investigating the use of deep brain stimulation (DBS) as a treatment for patients with Alzheimer’s disease. DBS is currently FDA approved to treat Parkinson’s disease, Tourette’s syndrome and resistant Obsessive Compulsive Disorder.

The collaboration of the two hospitals is part of a multisite, global study evaluating the safety and efficacy of DBS in slowing the loss of memory and cognitive abilities in patients with Alzheimer’s disease. DBS is ‘pacemaker-like device’ that is surgically implanted to stimulate the fornix area of the brain – an area known to play a central role in memory.

An early phase trial with 6 patients showed promise. That study found that patients with mild forms of the disease showed sustained increases in glucose metabolism, an indicator of neuronal activity, over a 13-month period. Most patients with Alzheimer’s disease show decreases in glucose metabolism over the same time period.

The larger study is a double-blind clinical trial where all participants will have the device implanted. Half of the participants will have the device activated in the first year, and all participants will receive active stimulation in the second year of the study.

Source: AAAS and EurekAlert
For more information: http://www.ADvanceStudy4AD.com

Posted in Alzheimer's Disease, Clinical trial, Cognition, Deep Brain Stimulation, Dementia, Uncategorized | Comments Off

White House Conference on Mental Health

Posted on June 5, 2013 by rkennedy

This week, the White House organized a conference on mental health with a particular emphasis on stigma and awareness. President Barack Obama opened the conference by calling for a more robust national discussion on mental illness, saying the time had come to bring the issue “out of the shadows.” He added, that his goal was to let people who are affected by these issues know they should not suffer in silence.

“Struggling with a mental illness or caring for someone who does can be isolating,” Obama said. “It begins to feel as if, not only are you alone, but that you shouldn’t burden others with the challenge.”

Top administration officials, along with actors Bradley Cooper and Glenn Close, were among those participating in the White House conference. Cooper has been promoting mental health awareness since his Oscar-nominated leading role as a man with bipolar disorder in last year’s “Silver Linings Playbook.”  Close said Monday that her experience is “a family affair,” and that her sister, Jessie, was diagnosed with bipolar disorder at 51 and Jessie’s son, Calen, was diagnosed with schizoaffective disorder at 19. Close started a non-profit called Bring Change 2 Mind, which produces public service announcements to fight the stigma and discrimination associated with mental illness.

The conference agenda includes discussion of insurance coverage for mental health care and substance abuse, recognizing the signs of mental illness in young people and improved access to services for veterans. The overall goal is reducing the stigma of mental health problems and encouraging those who are struggling to get help.

The American Psychiatric Association (APA) was well represented at the National Conference on Mental Health hosted by President Obama and Vice-President Biden.

Invited to attend the conference were APA President Jeffrey Lieberman, M.D., Psychiatric News Editor-in-Chief Jeffrey Borenstein, M.D., who is also president and CEO of the Brain & Behavior Research Foundation, and APA President-elect Paul Summergrad, M.D. Summergrad was representing the American Hospital Association, where he is chair of  the Governing Council for Psychiatry and Substance Abuse Services. (In photo, from left, are Jeffrey Borenstein, M.D., Patrick Kennedy, Paul Summergrad, M.D., and Jeffrey Lieberman, M.D.)

To provide information and resources about mental health, the Department of Health and Human Services today launched a new Web site, www.mentalhealth.gov.

Posted in Bipolar Disorder, Disability, Discrimination, Mental health, Stigma | Comments Off

New Guidelines on Sleep Apnea

Posted on June 3, 2013 by rkennedy

The American Thoracic Society (ATS) has released new clinical practice guidelines on sleep apnea, sleepiness, and driving risk on non-commercial drivers. Published in the June, 2013 American Journal of Respiratory and Critical Care Medicine, the new guidelines, are an update of a 1994 ATS statement on sleep apnea.
It is estimated that up to 20 percent of crashes that occur on monotonous roads can be attributed to sleepiness, and the most common medical cause of excessive daytime sleepiness is obstructive sleep apnea (OSA).

The guidelines’ recommendations include the following:

• All patients undergoing initial evaluation for suspected or confirmed OSA should be asked about daytime sleepiness and recent unintended motor vehicle crashes or near-misses attributable to sleepiness, fatigue, or inattention. These characteristics are considered high-risk and these drivers should be warned about the potential risk of driving until effective therapy is initiated.
• Assessment should be made of the severity of the OSA and treatment that the patient has received, including behavioral interventions. Adherence and response to therapy should be assessed at subsequent visits.
• For patients in whom there is a high clinical suspicion of OSA and who have been deemed high-risk drivers:

  • Polysomnography should be performed and, if indicated, treatment initiated as soon as possible, rather than delayed until convenient.
  • Empiric continuous positive airway (CPAP) should not be used for the sole purpose of reducing driving risk.

• For patients with confirmed OSA who have been deemed high-risk drivers, CPAP therapy to reduce driving risk is recommended, rather than no treatment.
• For patients with suspected or confirmed OSA who have been deemed high-risk drivers, stimulant medications for the sole purpose of reducing driving risk are not recommended.
• Opportunities to improve clinical practice include the following:

  • Clinicians should develop a practice-based plan to inform patients and their families about drowsy driving and other risks of excessive sleepiness, as well as behavioral methods that may reduce those risks.
  • Clinicians should routinely inquire in patients suspected with OSA about non-OSA causes of excessive daytime sleepiness, co-morbid neurocognitive impairments, and diminished physical skills, which may additively contribute to crash risk and affect the efficacy of sleep apnea treatment.
  • Clinicians should familiarize themselves with local and state statutes or regulations regarding the compulsory reporting of high-risk drivers with OSA.

2013 Guidelines

Posted in Cognition, Excessive sleepiness, Guideline, Sleep, Sleep Apnea | Comments Off

Interns may devote only 12% of their time to patients

Posted on May 31, 2013 by rkennedy

In the New York Times (5/30) “Well” blog, Pauline W. Chen, MD, writes that a “dramatic decrease in time spent with patients compared with previous generations appears to be linked to new constraints young doctors now face, most notably duty hour limits and electronic medical record-keeping.”

She cites a recently published study in the Journal of General Internal Medicine showing results that interns now spend almost half their days in front of a computer screen, more than they do with patients. When the study authors “calculated the amount of time spent face to face with patients, the researchers found that interns were devoting about eight minutes each day to each patient, only about 12 percent of their time.”

Researchers from John’s Hopkins and University of Maryland School of Medicine studied whether the Accreditation Council for Graduate Medical Education (ACGME) Common  Program Requirements, that were launched in July of 2003 and revised in 2011, which limit continuous and total work hours for interns and increase supervision requirements impact time spent directly with patients. They assessed whether limiting the length of shifts and total time in the hospital, particularly for interns, will reduce the time spent at the patient’s bedside and alter the balance between service and learning.

Researchers  recorded intern activities at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012. Using the iPod Touch™ “TimeTracker” application. The application allows observers to track intern time utilization in a variety of activities in real-time, including multitasking (a total of 873 intern hours). Data collection was anonymous.

Results  showed that “interns in this study spent a minority of their time, approximately 12 %, in direct contact with patients. Two-thirds of intern time was spent in indirect patient care, including entering orders, consulting with other physicians, writing notes, and reading the patient chart. Interns spent 40 % of their time in front of computer screens, and more time reviewing patient charts than directly engaging patients.”

Study authors point out that “The goal of residency training is to produce competent
physicians capable of practicing independently. To reach the educational milestones needed to demonstrate independence, residents must hone their skills in patient care and
communication. As the ACGME common program requirements highlight, “For the resident, the essential learning activity is interaction with patients under the guidance and
supervision of faculty members.” Prior studies have found that more time spent with patients may improve patient satisfaction, patient education, and clinical outcomes, and
reduce inappropriate prescribing.

Chen P. NY Times Well Blog, May 30, 2013
Block L, et al. J Gen Intern Med. 2013

 

Posted in Education, Electronic Medical Record, Medical Education, Quality health, Technology | Comments Off

David Kupfer, MD Responds to NIMH Criticism of DSM-5

Posted on May 7, 2013 by rkennedy

David Kupfer, M.D, chair of APA’s DSM-5 Task Force responds to recent criticism of DSM-5 and its previous iterations by NIMH Director Thomas Insel, M.D. In a statement issued, Dr Kupfer emphasized that the diagnostic manual “provides clinicians with a common language to deliver the best patient care possible” and is “the strongest system currently available for classifying disorders.”

Kupfer stated that “efforts like the National Institute of Mental Health’s Research Domain Criteria [RDoC] are vital to the continued progress of our collective understanding of mental disorders.” He continued by noting that Insel’s vision of a system based on biological and genetic markers “remains disappointingly distant” and “cannot serve us in the here and now.” It “merely hand[s] patients another promissory note that something may happen sometime. Every day,” he said, psychiatrists must respond to patients who are suffering. “Our patients deserve no less.”

Dr Kupfer’s complete statement is posted at http://www.psych.org/File%20Library/Advocacy%20and%20Newsroom/Press%20Releases/2013%20Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf.

 

 

Posted in Diagnosis, DSM-5 | Comments Off

National Institute on Mental Health Abandons DSM-5

Posted on May 5, 2013 by rkennedy

Two weeks before DSM-5 goes on sale, Thomas Insel,  Director of the National Institute on Mental Health (NIMH) writes that the DSM lacks validity and that “patients with mental disorders deserve better”.

According to Dr Insel, “The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”

NIMH believes that a diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. There is a need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.

That is why NIMH will be re-orienting its research away from DSM categories. “Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.” NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.

According to Dr Insel, “RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning.”

Read Dr Insel’s announcement “Transforming Diagnosis”

 

Posted in Diagnosis, DSM-5, NIMH, Research | Comments Off

Pain conditions among veterans with schizophrenia or bipolar disorder

Posted on May 3, 2013 by rkennedy

A study published in General Hospital Psychiatry evaluated the rates of chronic, noncancer pain conditions in patients diagnosed with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.

Researchers used a cross-sectional design that used administrative data extracted from VHA treatment records of all individuals receiving VHA services in one year (N=751). They evaluated the associations between severe psychiatric disorders, such as, schizophrenia and bipolar disorder and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic pain).

The results revealed that noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. The authors suggested that future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.

Pain conditions among veterans with schizophrenia or bipolar disorder. General Hospital Psychiatry. May 1, 2013

Posted in Bipolar Disorder, Chronic Pain, Pain, Schizophrenia | Comments Off

Essential Components of First-Episode Psychosis Services

Posted on May 1, 2013 by rkennedy

A study published in May 1st, 2013 Psychiatric Services identified essential evidence-based components of first-episode psychosis services. The research took place in two stages. First a systematic literature review, then, a consensus-building technique, the Delphi, was used with an international panel of experts. The panelists were presented the evidence-based components identified in the review, together with the level of supporting evidence for each component. They rated the importance of each component on a 5-point scale. A score of 5 was required to determine that a component was essential.

This two-step process yielded a manageable list of 32 evidence-based components of first-episode psychosis services. Given the proliferation of such services and the absence of an evidence-based fidelity scale, this list can form a foundation for developing a fidelity scale for such services. It may also be helpful to funders and providers as a summary of essential services.

The study yielded an interesting group of essential services and approaches divided by domain and component. For example:

Population-level interventions and access
- this domain stressed public and healthcare provider education, communication among providers and availability of treatment for comorbid conditions
Comprehensive assessments and care plan
- highlighted the importance of individual-centered assessments, suicide assessment, psychosocial care plans, etc.
Individual-level interventions
- this domain included pharmacotherapy including medication choices, low dosing, metabolic monitoring, etc
-also included is psychoeducation, addiction treatment, vocational and educational planning
Group-level interventions
- including multi-family and group therapies
Service system and models of intervention
- this stressed team approaches, staff supervision, outreach programs, crisis intervention services
Evaluation and quality improvement
- continual evaluation and outcome measures

The researchers concluded that “our review found an adequate corpus of research on first-episode psychosis services to inform a panel of experts in identifying evidence-based components. The Delphi was successful in reducing evidence-based components to 32 essential components. Pharmacological components generally had the highest level of supportive evidence, although psychosocial components, such as family psychoeducation or multifamily group psychoeducation and supported employment, both had level A evidence. The lack of evidence for a number of organizational components reflects the lack of attention paid to these issues in the research literature.”

Psychiatric Services 2013;64:452–457

Posted in Addiction, Adherence, Antipsychotic medication, Early intervention, Measurement-based care, Mental health, Metabolic screening, Professionalism, Psychosis, Schizophrenia | Comments Off

L-Dopa Improves Decision-Making In Older Adults

Posted on March 26, 2013 by rkennedy

A study published online  in Nature Neuroscience has demonstrated that a drug widely used to treat Parkinson’s Disease can help to reverse age-related impairments in decision making in some older people.  Researchers from Wellcome Trust Centre for Neuroimaging describe the changes in the patterns of brain activity of adults in their seventies that help to explain why they are worse at making decisions than younger people.

Poorer decision-making is a natural part of the aging process that is believed to stem from a decline in our brains’ ability to learn from our experiences. Part of the decision-making process involves learning to predict the likelihood of getting a reward from the choices that we make. The nucleus accumbens area of the brain is responsible for interpreting the difference between the reward that we’re expecting to get from a decision and the reward that is actually received. These so called ‘prediction errors’, are modulated by dopamine to help us to learn from our actions and modify our behavior to make better future choices.

Researchers using a combination of behavioral testing and brain imaging techniques,  investigated the decision-making process in 32 healthy volunteers in their early seventies compared with 22 volunteers in their mid-twenties. Older participants were tested on and off L-DOPA, a drug that increases levels of dopamine in the brain – a drug that is widely used to treat Parkinson’s disease.

The participants were asked to complete a behavioral learning task called the two-arm bandit, which mimics the decisions that gamblers make while playing slot machines. Players were shown two images and had to choose the one that they thought would give them the biggest reward. Their performance before and after drug treatment was assessed by the amount of money they won in the task.

The older subjects performed worst in the task, and were less able to predict the likelihood of a reward from their decisions. They did, however,  demonstrate a significant improvement following drug treatment.

The researchers then looked at brain activity in the participants as they played the game using functional Magnetic Resonance Imaging (fMRI), and measured connections between areas of the brain that are involved in reward prediction using  Diffusor Tensor Imaging (DTI).  The findings reveal that the older adults who performed best in the gambling game before drug treatment had greater integrity of their dopamine pathways. Older adults who performed poorly before drug treatment were not able to adequately signal reward expectation in the brain – this was corrected by L-DOPA and their performance improved on the drug.

Nature Neuroscience

Posted in Cognition, Genetics, Imaging, Memory, Neuroscience | Comments Off

Dementia is the Second Largest Contributor to Death

Posted on March 20, 2013 by rkennedy

According to a report released this week by the Alzheimer’s Association, one in three seniors dies with Alzheimer’s or another dementia in the United States. The new Alzheimer’s Association 2013 Alzheimer’s Disease Facts and Figures report shows that while deaths from other major diseases, such as heart disease, HIV/AIDS and stroke, continue to experience significant declines, Alzheimer’s deaths continue to rise — increasing 68 percent from 2000-2010.

Alzheimer’s disease is the sixth-leading cause of death in the United States and is the only leading cause of death without a way to prevent, cure or even slow its progression. Based on 2010 data, Alzheimer’s was reported as the underlying cause of death for 83,494 individuals — individuals who died from Alzheimer’s. Alzheimer’s Association 2013 Facts and Figures reveals that in 2013 an estimated 450,000 people in the United States will die with Alzheimer’s. The true number of deaths caused by Alzheimer’s is likely to be somewhere between the officially reported number of those dying from and those dying with Alzheimer’s.

According to Alzheimer’s Association 2013 Facts and Figures, a recent study evaluated the contribution of individual common diseases to death using a nationally representative sample of older adults and found that dementia was the second largest contributor to death behind heart failure. Among 70-year-olds with Alzheimer’s disease, 61 percent are expected to die within a decade. Among 70-year-olds without Alzheimer’s, only 30 percent will die within a decade.

Special Focus on the Long-Distance Caregiving Experience

2013 Facts and Figures also explores the challenges faced by long-distance caregivers for people living with Alzheimer’s. The report finds that nearly 15 percent of caregivers for people with Alzheimer’s or another dementia are “long-distance caregivers” — caring for people with Alzheimer’s disease who live at least 1 hour away. These long-distance caregivers had annual out-of-pocket expenses nearly twice as high as local caregivers — $9,654 compared to $5,055.

For more information: Alzheimer’s Association

The full text of the Alzheimer’s Association 2013 Alzheimer’s Disease Facts and Figures can be viewed at www.alz.org/alzheimers_disease_facts_and_figures.asp

Posted in Alzheimer's Disease, Dementia | Comments Off