Chair Summit 2014


A very successful 7th Annual Chair Summit 2014 took place this past weekend in Tampa, Fla. Faculty leading this interesting series of plenaries, breakout sessions and chart reviews are Chairmen of departments of psychiatry and neurology and the leading researchers and clinicians in the field. They shared a mix of cutting edge science and practical, clinical pearls of wisdom to a sold-out audience. The focus of these timely discussions was ‘clinical connections’ that can be useful in everyday practice.

Interactivity is a key element of this 3 day conference. Larger sessions incorporated audience participation through a network of laptop computers, tablets and smartphones – all connected to the faculty. Questions, comments, and Twitter posts expanded the dialogue beyond the usual ‘audience response system’ to create an immersive sense that everyone was part of this educational network. Small group sessions were hands-on workshops where participants could discuss clinical challenges and many asked questions about difficult cases in their own practice. There were also sessions to complete part of the performance-in-practice component of the ABPN maintenance of certification requirements in which attendees presented cases from their own practice to expert faculty in areas of schizophrenia, bipolar disorder, neurocognitive disorders and multiple sclerosis.

Topics offered were a spectrum of interesting, relevant new science and latest clinical approaches in areas of psychiatry and neurology and beyond. These included: schizophrenia, bipolar depression, major depression, PTSD, borderline personality, ADHD, multiple sclerosis, epilepsy, in addition to hot topics in medicine such as chronic pain, traumatic brain injury, obesity, food and substance addictions and sleep disorders.

The agenda, faculty and information about next years Chair Summit can be viewed at:


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Sense of Smell May Predict Risk for Cognitive Decline

alz-assnTwo studies presented at the 2014 Alzheimer’s Association International Conference (AICC) in Copenhagen this month demonstrated that a decrease in the ability to identify odors was significantly associated with loss of brain cell function and progression to Alzheimer’s disease. There is growing evidence that the decreased ability to correctly identify odors is a predictor of cognitive impairment and an early clinical feature of Alzheimer’s disease.

Researchers from the Harvard Brain Study, evaluated olfaction via the University of Pennsylvania Smell Identification Test (UPSIT) in 215 clinically normal elderly individuals and administered a battery of cognitive tests. Also measured was the size of two brain structures – the entorhinal cortex and the hippocampus and levels of amyloid deposits in the brain.  They found that a smaller hippocampus and a thinner entorhinal cortex were associated with worse smell identification and worse memory.

From 2004 to 2010, Columbia University Medical Center researchers studied a multi-ethnic group of 1,037 senior citizens without a diagnosis of cognitive dysfunction to determine whether a relationship exists between the inability to identify smells and a diagnosis of mild cognitive decline. The research showed that in subjects with low UPSIT scores, “210 participants transitioned to either dementia or Alzheimer’s disease (AD) during follow-up two to four years after initial UPSIT was administered. Transition to dementia and AD was correlated with lower odor-identification scores on the UPSIT.”

Of all of the subjects who were followed over the years,  lower odor-identification scores were significantly associated with the transition to dementia and Alzheimer’s disease. For each point lower that a person scored on the UPSIT, the risk of Alzheimer’s increased by about 10%. In addition, lower baseline UPSIT scores, but not measures of verbal memory, were significantly associated with cognitive decline in participants without baseline cognitive impairment. “Odor identification deficits were associated with the transition to dementia and Alzheimer’s disease, and with cognitive decline in cognitively intact participants, in our community sample.”

For many years, olfactory deficits have been associated with Parkinson’s disease. “Impairment of olfaction is a characteristic and early feature of Parkinson’s disease. Recent data indicate that >95% of patients with Parkinson’s disease present with significant olfactory loss.”

According to the Alzheimer’s Association, “In the face of the growing worldwide Alzheimer’s disease epidemic, there is a pressing need for simple, less invasive diagnostic tests that will identify the risk of Alzheimer’s much earlier in the disease process.”

This same sense of urgency applies to Parkinson’s disease.

Alzheimer’s Association International Conference press release
Haehner A, et al Olfactory Loss in Parkinson’s Disease


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Watching Individual Neurons Respond During Transcranial Magnetic Stimulation

natureneuroTranscranial magnetic stimulation (TMS) is used to treat refractory major depression. Until now, there was no way of knowing exactly what changes were taking place in the brain as a result of treatment. Duke University neuroscientists and engineers have developed a way to measure the response of an individual neuron to TMS.

Measuring neural responses during the procedure has been difficult as the comparatively tiny activity of a single neuron is lost in the tidal wave of current being generated by TMS. The research team at Duke engineered new hardware that could separate the TMS current from the neural response, which is thousands of times smaller. They were able to focus in and successfully recorded the action potentials of an individual neuron moments after TMS pulses and observed changes in its activity that significantly differed from activity following placebo treatments.

This study is published in Nature Neuroscience, June 29, 2014

Mueller, JK et al.
Nature Neuroscience

Posted in Depression, Neuroscience, Transcranial magnetic stimulation, Treatment, Treatment resistant depression | Comments Off

Comparison of DSM-IV Versus DSM-5 ADHD Criteria Supports Revision

A study published in the Journal of the American Academy of Child and Adolescent Psychiatry compares ADHD diagnosed via the DSM-IV criteria and the new DSM-5 in youth.  Researchers from the National Institute of Mental Health compared the prevalence and clinical correlates of ADHD as described in the two DSM editions in a nationally representative sample of U.S. youth with a particular focus on the age-of-onset criterion. The sample included nearly 1,900 participants aged 12 to 15 from cross-sectional National Health and Nutrition Examination Survey (NHANES) surveys conducted from 2001 to 2004.

The results demonstrated that the DSM-5 extension of the age-of-onset criterion from 7 to 12 led to an increase in the prevalence rate of ADHD from 7.38% (DSM-IV) to 10.84% (DSM-5). Importantly, youth with later age of onset did not differ from those with earlier age of onset in terms of severity and patterns of comorbidity. The researchers concluded that “the comparability of the clinical significance of the early and later age-of-onset groups supports the DSM-5 extension of the age-of-onset criterion in ADHD.”

Article in Press
Impact of the DSM-5 Attention-Deficit/Hyperactivity Disorder (ADHD) Age of Onset Criterion in the U.S. Adolescent Population

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Adolescents, antidepressants and suicide

Screen shot 2014-04-30 at 10.31.56 AM

A meta-analysis of clinical trial data published this week in JAMA Internal Medicine suggests that risk for suicidal behavior is twice as likely when children and young adults who are diagnosed with depression are given antidepressants compared to placebo.  A key factor appeared to be dose of the antidepressant.  The researchers found that younger patients who began treatment with higher-than-recommended doses of antidepressants were more than twice as likely to try to harm themselves as those who were initially treated with the same drugs at lower, recommended doses. Interestingly, the analysis found no increased risk of suicidal behavior among adults older than 24 who started medical treatment for depression at larger initial doses.

The study reviewed medical records of 162,625 U.S. residents, ages 10 to 64, who were diagnosed with depression and prescribed an SSRI between 1998 and 2010. It found that more than half of antidepressants in that period were prescribed by primary care doctors, and another 25% by practitioners not specialized in mental health. Even in children, fewer than 30% of antidepressant prescriptions were issued by psychiatrists. The authors pointed out that they could not discern why younger patients on high initial doses of antidepressant were more likely to try to harm themselves. While it could have been the dose that they were started on, it could also be that younger patients who may have been viewed as being in crisis were treated more aggressively with higher doses.

An accompanying commentary in JAMA Internal Medicine suggests that the best approach is to “Start low and go slow.”


M Miller, et al. Antidepressant Dose, Age, and the Risk of Deliberate Self-harm
D Brent, et al. Commentary: Initial Dose of Antidepressant and Suicidal Behavior in Youth. Start Low, Go Slow

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Do Men and Women Experience Depression Differently?

AJPKenneth Kendler, M.D., a professor in the departments of Psychiatry and Human and Molecular Genetics at Virginia Commonwealth University School of Medicine, and colleagues studied 1,057 adult opposite-sex dizygotic twin pairs for the incidence of major depression within a given year, and identified 20 risk factors that may contribute to such incidences. They found that 11 of the 20 risk factors differed across gender lines as they relate to the development of major depression.

For women there were 5 factors that had greatest impact: parental warmth, neuroticism, divorce, social support, and marital satisfaction. Six had a greater impact in men: childhood sexual abuse, conduct disorder, drug abuse, prior history of major depression, and distal and dependent proximal stressful life events. The authors point out that ‘the developmental pathways to depression in men and women share some important elements, but on average differ from each other in some important ways.’

The researchers concluded that in this co-twin control design, which matches sisters and brothers on genetic and familial-environmental background, ‘personality and failures in interpersonal relationships played a stronger etiologic role in major depression for women than for men, whereas, externalizing psychopathology, prior depression, and specific “instrumental” classes of acute stressors were more important in the etiologic pathway to major depression for men.’ It would be interesting to see how these factors would translate into psychotherapeutic approaches and responses to treatment.

Am J Psychiatry 2014 [Epub]

An interesting related article appeared in JAMA Psychiatry last year.

The Experience of Symptoms of Depression in Men vs Women
Analysis of the National Comorbidity Survey Replication

Posted in Chronic illness, Depression, Gender, Genetics | Comments Off

Prevalence of Mental Disorders in Mid-life and Older Adulthood Greater than Previous Reported

JAMAA new study published in JAMA Psychiatry evaluated retrospective and cross-sectional surveys of reported statistics of mental health disorders and compared those results with reports of physical disorders. Interviews of 1071 adults who participated in the Baltimore Epidemiologic Catchment Area Survey which included a series of interviews that spanned a period of 24 years, revealed that participants dramatically underreported mental health problems compared to physical complaints. Mental health disorder categories included: major depressive disorder; obsessive-compulsive disorder; panic disorder; social phobia; alcohol abuse or dependence and drug abuse or dependence. The physical disorders reviewed included: diabetes, hypertension, arthritis, stroke, and cancer. These were much more accurately reported.

The authors suggest that possibly the stigma associated with mental illness could be a factor and conclude that “population surveys may consistently underestimate the lifetime prevalence of mental disorders. The population burden of mental disorders may therefore be substantially higher than previously appreciated.”

JAMA Psychiatry. Published online January 08, 2014

Posted in Epidemiology, Geriatrics, Mental health | Comments Off

APA Reviews Maintenance of Certification

apalogoThe American Psychiatric Association (APA) published a review and summary of the maintenance of certification (MOC) requirements for the American Board of Psychiatry and Neurology (ABPN). This review is designed to assist members to prepare for the ABPN re-certification process.

The new document outlines the schedule that the ABPN is using to phase in various components of the MOC requirement based on the year in which a psychiatrist was originally certified. It also details the total number of CME credits required by year of original certification and the program units that psychiatrists will need to complete. In addition, the document describes components and requirements of the Continuous Pathway to Lifelong Learning Program (CP-MOC) for diplomates certified or recertified in 2012 or later.

Here is an article that explains the goals and background of MOC program.

Link to the ABPN MOC page.

Posted in Maintenance of Certification, Medical Education | Comments Off

Task Force Report on Antidepressant Use in Bipolar Disorders

alp-journalThe International Society for Bipolar Disorders (ISBD) Task Force Report on Antidepressant Use in Bipolar Disorders has been published in the American Journal of Psychiatry. The task force commented that there is “striking incongruity between the wide use of and the weak evidence base for the efficacy and safety of antidepressant drugs in bipolar disorder.”

Some highlights of the Task Force Recommendations:

Acute treatment
1. Adjunctive antidepressants may be used for an acute bipolar I or II depressive episode if there is a history of previous positive response to antidepressants.

2. Adjunctive antidepressants should be avoided for an acute bipolar I or II depressive episode with two or more concomitant core manic symptoms in the presence of psychomotor agitation or rapid cycling.

Maintenance treatment
Adjunctive antidepressants with adjunctive antidepressants may be considered if a patient relapses into a depressive episode after stopping antidepressant therapy.

Monotherapy with antidepressants in Bipolar I should be avoided.

Switch to mania, hypomania, or mixed states and rapid cycling
Bipolar patients starting antidepressants should be closely monitored for signs of hypomania or mania and increased psychomotor agitation, in which case antidepressants should be discontinued.

The task force concluded that because of limited data, no broad endorsements were issued  but it acknowledged that some bipolar patients may benefit from antidepressants. When commenting about safety, the report commented that “serotonin reuptake inhibitors and bupropion may have lower rates of manic switch than tricyclic and tetracyclic antidepressants and norepinephrine-serotonin reuptake inhibitors.” Both the severity and frequency of antidepressant-associated mood elevations appear to be greater in bipolar I than bipolar II disorder. And, antidepressants should be prescribed only as an adjunct to mood-stabilizing medications in bipolar I patients.

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Violence and Schizophrenia: The Subject of ’60 Minutes’

60minThe CBS television program “60 Minutes” aired a special report about the issue of recent tragic mass shootings as preventable tragedies and the failures of the US mental health system. The show interviewed experts Jeffrey Lieberman, M.D., president of APA and chair of psychiatry at Columbia University, and E. Fuller Torrey, M.D., executive director of the Stanley Medical Research Institute. In addition, individuals with schizophrenia and their relatives were also interviewed.

Salient points from this program were highlighted:

1) Schizophrenia is a brain illness.
2) Many receive inadequate treatment
3) Viable treatments are available

Dr Lieberman discussed imaging of brain changes in schizophrenia and described the symptoms which can include command auditory hallucinations that may be telling these individuals what to do and how this devastating illness affects perception and judgment. Drs Lieberman and Torrey emphasized that the vast majority of individuals with schizophrenia do not commit violence. Most suffer from this lifelong illness without adequate access to treatment in their communities. And what is even more tragic is that as a result of suboptimal treatment, many people with serious mental illness end up in jails and prisons.

Effective treatments are available for the symptoms such as hallucinations or delusions that individuals with schizophrenia experience, but access to such treatments is not always available. In some cases, because of their illness, they refuse treatment or won’t acknowledge their illness.  Some of these untreated individuals with schizophrenia may listen to their “voices” telling them to commit violence.

60 Minutes TV Segment


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