SDACAP NEWS
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March 31, 2009
Volume 2, Issue 1
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Individual Highlights:
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Special Interest Articles:
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What is this newsletter?
This newsletter is the first issue in the second volume of what we hope to be a quarterly publication. We invite comments, opinions, discussions and complaints. Clinical information presented in this letter is not meant to be a substitute for sound medical judgment. Please send any correspondence to our email listed below.
SDACAP Officers:
President- Jeff Rowe
Secretary/Treasurer- Donna Mehregany
Assembly Delegates- Mark Chenven, Lisa Ponfick
Member at Large0 Richard Buccigross
Cal-ACAP Rep- Mike Tramell
Early Career Officers- Neha Bahadur, Nicodemus Watts
Executive Administrator- Angie Corrales
E-Mail: sandiegoacap@yahoo.com
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President’s Column- Jeff Rowe
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Relationships with Pharmaceutical Companies
The orange journal (AACAP), the green journal (APA), newspapers (NY Times), magazines (Newsweek), and the TV news seem to all be filled with reports
about doctors and the huge amounts of money they have made for their work
with the pharmaceutical companies. Last month’s guest column by Larry Schmitt went into the issue at length to describe how hard it is to not be influenced by
money, advertisements, trinkets, and friendships with the representatives of
these companies. Some of us have given lectures for these companies, some have considered doing it, and some have longed to be asked. It is hard to claim “no influence”.
As psychiatrists it is important to be honest and open about these influences and relationships. We stand in a particularly unusual position with respect to our patients and the pharmaceutical companies. The drug companies do provide a vital service – they make the stuff we prescribe. Without them, there would not likely be new medications or improvements on those about to go “off patent”. Our patients and their families depend on the good, solid safety and effectiveness research that goes into bringing a drug to market. Of course, this is where it gets complicated; the market. Pharmaceutical companies are profit-making enterprises. They are not benevolent foundations charged with curing an illness. We should not expect them to act solely
in a client’s interest, and we should expect them to try to emphasize the good aspects of their product and minimize the bad – just as any profit making company would.
We need to clearly label and explain our relationships with these companies; to our patients, to our colleagues, and to our employers. To do otherwise, can be interpreted as being misleading about our impartiality about certain medications and their uses. This risks damage to our reputation, as a hidden relationship that results in significant payment can be construed, or misconstrued, to be unethical or against our oath to do no harm and to hold our patient’s interest as primary. Several prominent psychiatrists are dealing with this now. It is not certain that they have done anything wrong, but the fact that unreported relationships have been going on for years diminishes the value of their research and advocacy work.
Our knowledge, our ability, and our reputation are not easily gained and certainly not easily regained once lost. Make sure you are open about your relationships with pharmaceutical companies to your patients, your colleagues, and your employers.
(Jeff is the Supervising Psychiatrist for the County of San Diego Children’s Mental Health Services)
Spotlight on Special Programs- Anna Carrillo
Sharp Mesa Vista CHANGES Program/UCSD Child and Adolescent Residency
Substance abuse among adolescents remains at alarming rates. Children and adolescents with severe psychiatric disorders are at higher risk for substance misuse. In particular, studies of residential and hospital settings have reported that as many as 40% of adolescents met criteria for a co-morbid cannabis or alcohol abuse disorder. Within the juvenile justice system, this statistic is grimmer with 80% of juvenile delinquents having a substance abuse or substance dependence disorder. These statistics highlight the need for child and adolescent psychiatrists to be both knowledgeable and proficient in the treatment of substance abuse disorders in youth.
To meet this demand, University of California at San Diego’s Psychiatry Residency Program has formed a partnership with Sharp Mesa Vista’s CHANGES program, an intensive outpatient program for adolescents with co-occurring substance abuse and mental health disorders. This collaboration began four years ago and was initially a voluntary rotation. However, this rotation is now a requirement for all psychiatric residents for several reasons. First, there is a paucity of training opportunities in substance abuse and dependence treatment for psychiatric residents. The psychiatric community has historically separated treatment of chemical dependency and mental health disorders. Second, the rates or substance abuse and dependence in the community’s youth have maintained at significantly high levels. Thus, it is essential to provide training to psychiatric residents in this relevant area.
During the month-long rotation, residents learn several skills to prepare for both understanding and treating adolescent chemical dependency. They will hone their motivational interviewing skills, an evidence-based best practice in the treatment of substance abuse and dependence, by observing and participating in group therapy sessions. Residents will also learn about family system dynamics and the factors that contribute to substance abuse/dependence. The opportunity to apply family systems theories and interventions is provided by observing and participating in the multi-family therapy groups that occur weekly. Overall, the rotation through the CHANGES program provides a unique opportunity for future child and adolescent psychiatrists.
(Anna is a former resident from the UCSD General Psychiatry Program. She is now a child psychiatrist working for Sharp Mesa Vista Hospital and the San Pasqual Academy.)
Administrative Issues- Angie Corrales
Monthly Meetings:
Your San Diego regional organization meets on the fourth Wednesday of each month at Sharp Mesa Vista Hospital. Our meetings are open to all members (and lunch is provided). We are considering rotating our meetings throughout various locations in San Diego to facilitate your participation. Let me know if your facility would be interested in hosting a meeting. Please contact Angie Corrales at sandiegoacap@yahoo.com to attend or to host a meeting.
Medical Student Grant Award:
SD ACAP is happy to report that we were awarded a $600 Medical Student Grant which we are in the planning stages of utilizing. An idea being considered is an opportunity for an informal dinner/meeting for medical students to meet with our Executive Council.
Advocacy Grant Submission:
We are happy to report that we have once again been awarded the 2009 AACAP Advocacy Grant! The Psychological Trauma and Kids Mini-Symposium we held in October with funds awarded from the 2008 AACAP Advocacy Grant award was such a success, we are hoping to hold a part II with the newest award. More information will follow.
Contact Information Updates:
We want to stay connected! Please make sure you submit your contact information changes promptly so you don’t miss any announcements. Send your changes to Angie Corrales sandiegoacap@yahoo.com
Medication News- Nicodemus Watts
Placebo Response in Randomized Controlled Trials of Antidepressants: Important Implications for Future Studies of Major Depressive Disorder in Pediatric Populations
A recent review of antidepressant trials for patients 6-18 years old has revealed that a “shift toward multisite trials of antidepressant medications for pediatric major depressive disorder may be contributing to an increase incidence of response to placebo.” These are the conclusions drawn from a recent study published in the American Journal of Psychiatry. The authors reviewed 12 randomized controlled trials (2,862 patients) using a PubMed search from January 1988 through July 2006. The meta-analysis revealed a 48% response to placebo and a 56% response to second generation antidepressants. An important inclusion criterion was response data for both participants treated with placebo and antidepressant as measured by improvement on the Clinical Global Impression (CGI) scale. Response criteria was a end-of-treatment rating of ≤2 (“much improved” or “very much improved”) on the CGI improvement item, thus indicting a significant reduction in depressive symptoms. The study illustrated that the “single best predictor of the proportion of patients taking placebo who responded to treatment was the number of study sites.”
The study concludes that restricting the study sites to “a few select centers with experience in clinical assessment of pediatric mood disorders may allow for more careful selection of participants and improved quality assurance over the methods individual sites use to approach, recruit, and retain the patients under study.” In addition, an important indicator of response to placebo was found to be the severity of depression from the study outset. Those patients that experienced a “mild functional impairment” illustrated greater response to placebo than more severe depressive illness. Thus, the authors suggest there is a role for brief supportive therapy being instituted first line in young patients suffering mild depression without considerable loss in function. In addition, studies focusing on moderately to severely depressed youths have a higher probability of determining if mediations truly have an antidepressant effect.
Source: Bridge, JA, Birmaher B, Iyengar S, Barbe RP, Brent DA: Placebo Response in Randomized Controlled Trials of Antidepressants for Pediatric Major Depressive Disorder. Am J of Psychiatry 2009; 166:42-49.
Extended-Release Guanfacine (GXR) – New Study Reveals Promising Results
Guanfacine, a selective α2A adrenoreceptor agonist, has widely been used off-label as a treatment for some patients with ADHD. A new study reveals promising findings in ADHD symptom reduction with extended-release Guanfacine (GXR). A primary limitation of guanfacine immediate-release has been the short duration of action necessitating multiple daily doses. Sallee and colleagues recently conducted a phase III, placebo-controlled trial with children/adolescents 6-17 y/o diagnosed with ADHD. The 9 week study of 322 patients took place at 51 sites in the US from March – October 2004. Patients were randomized to receive either placebo or GXR in once daily doses of 1, 2, 3, or 4 mg. Each of the GXR study group doses illustrated significant symptom reduction when compared to placebo. Effect sizes correlated with the size of the dose. Indeed, the study revealed that effect sizes for the highest doses were similar to those seen in studies of stimulants. Somnolence, sedation, and fatigue were observed during the first two weeks of the study yet, nearly dissipated at the conclusion of the study. There were only 2 patients that experienced clinically significant hypotension that lead to study discontinuation.
Source: Sallee FR, McGough J, Wigal T: Guanfacine Extended Release in Children and Adolescents with Attention Deficit Hyperactivity Disorder: A Placebo-Controlled Trial. J Am Acad Child Adolesc Psychiatry 2009; 48: 155-165.
(Nicodemus is a recent graduate of the UCSD Child Psychiatry Residency Training Program. He is in private practice in San Diego and works with Vista Hill and San Diego Center for Children.)
Member in Training Perspective- Jeanne Hong
Much like a child experiencing what Mahler described as the process of separation-individuation, I find myself experiencing a rather curious revisiting of this rite of passage as I approach the end of my fellowship. Throughout 4 years of medical school, 3 years of general psychiatry training, and almost 2 years of child training, most of my fellow trainees and I would discuss how much we looked forward to finally being done with training. With an inflated sense of our own capacity, we discussed times we felt mothered under the watchful eye of the training program while we dreamt about attaining the ultimate goal – “attending status”. Yet now as this concept is on the brink of materializing into a reality, I find myself hesitant to leave my secure base of my training program, with its structured schedules, dedicated didactic times, organized rotations, and comforts of being able to fall back on the wisdom of supervisors. The same watchful gaze that had felt omnipresent before, I’ve realized, is one that guides, affirms, and validates what we do.
Most of the tasks of being chief fellow have been ones that I have expected for the position, i.e., making call schedules, attending meetings with faculty and serving as a liaison between the faculty and fellows. There is a sense of gratification from being an advocate for the other fellows and I enjoy being able to contribute my thoughts on shaping the program. One of the best aspects of being chief has been the exposure to the different people that make up the many facets of child psychiatry. Through Resident Education Committee meetings, I have been able to see from the perspectives of the administration, learning to acknowledge just how much goes into
a training program and how many people are involved behind the scenes in order to create a solid program. As an invitee to the SDACAP meetings, I have observed how members of an organization dedicate their efforts to positively impact a community of child psychiatrists, and I have come to appreciate the value of informing and empowering one another as colleagues. It has truly changed my perspective of child psychiatry from not only treating at the level of an individual, but at the social, systems, and administrative levels. Many child psychiatrists perform varying roles, forming pathways that converge collectively for the common goal of promoting child and adolescent mental health.
I appreciate being around people who truly have a passion for child psychiatry as well as a dedication to investing in education for all of the fellows. I feel fortunate to be in such a diverse and dynamic field and am inspired by all of the possibilities. As tentative as I may be at times to leave my secure base at UCSD, I find comfort in knowing how much I have learned, both academically and personally, largely due to the efforts of the many attendings I have had the privilege to interact with. I look towards the future with some trepidation, but mainly excitement; and, armed with my Lewis textbook acting as my transitional object, I feel ready to explore.
(Jeanne is graduating from the UCSD Child Psychiatry Fellowship Program in June. She currently is the Chief Resident.)
Forensic Issues- Mike Tramell
The Roots of Antisocial Behavior
Recently I got involved in a discussion between two lawyers about a child who had committed a truly heinous act. They were bemoaning the tragedy of this minor and discussing the roots of one’s conscience; was it a biological mandate or early socialization that keeps so many of us from committing the terrible acts? How could someone “actually do something like that”, they wondered. I had to admit, that while we know some things, for the most part we do not know what drives individuals to antisocial behavior.
Serious study of antisocial behavior reveals multiple related risk factors. A major factor that contributes to a child acting in an antisocial manner is how the parents care for their child. Inconsistent discipline and lack of supervision combine with and reinforce many other risk factors such as associating with delinquent peers and experiencing abuse at an early age. Young men who have been abused appear to be at increased risk for conduct disorder, antisocial personality symptoms, and becoming violent offenders.
A second factor is witnessing violence in the neighborhood. Several studies have noted how serial killers often come from back-grounds of “horrendous abuse,” frequently including both physical and sexual abuse. This factor appears to be related to an in-crease in the occurrence of head injuries. About one fourth of serial killers interviewed in one study experienced at least one episode of unconsciousness after a head injury in childhood or early adolescence. It is easy to see how an unsupervised youth, in a violent neighborhood, who is abused and associating with other delinquent peers, may be at risk for a head injury.
A fourth factor is lack of friends. The rate of Schizoid Personality Disorder in those who commit antisocial acts has been estimated at about fifty times the general average (1%). These individuals are unable to form meaningful relationships and are essentially loners. Children with poor social skills and diminished social drive are frequently ostracized by their peers. This isolation widens the gulf between their social skills and those who are not ostracized, causing a worsening of their behavior, which only further isolates them and continues their downward spiral.
Risk of violence is a significant area to study as violent behavior is a particularly important type of antisocial behavior. A great deal has been written about risk factors of violent youth. These include a history of violence, and an early initiation into violence, past failures at attempting to correct violent behavior as well as other non-violent offending, past suicide attempts, exposure to violence in the home as well as parental criminality. Early caregiver disruptions and poor school performance are also associated with violence risk, as is community dis-organization. Other known individual risk factors for violence in youth include negative attitudes, impulsivity, substance use problems, anger management problems, low empathy, poor compliance with requests, and a low commitment to school.
There also appears to be a component of antisocial behavior and violent behavior that is genetically mediated. The gene most strongly associated with antisocial behaviors produces Monoamine Oxidase-A (MAOA), which is located on the X chromosome. This well known gene (to psychiatrists) is involved in the metabolism of dopamine, norepinephrine, and serotonin. In mice who have had this gene removed, increased levels of aggression were noted, which subsequently abated when this gene was restored. One family of men who exhibited multiple antisocial behaviors was reported to lack this gene entirely. A long version of this gene produces a gene product with a great deal of activity and a short version of this gene product appears to produce only a small level of activity. In a study by Caspi, 1000 boys were typed for the long or short versions of this gene, monitored for abuse throughout their childhood, and followed into adulthood. While those with the short version of the gene only accounted for 12 percent of the sample, those boys accounted for 44% of the cohorts convictions for violent acts. In those with both an abuse history and the short version of the gene, approximately 85% engaged in some form of antisocial behavior. Abuse however also continued to predict antisocial behaviors, even when the subject had the long (more active) version of the gene.
The interactions of the genes and the environment, however, are not entirely that simple. A behavioral genetics article by Feinberg, et al, in the April 2007 edition of Archives of General Psychiatry, noted that heritability (genes) influences antisocial behaviors more when parenting is negative and cold than when it is positive and warm. This would seem to suggest that while genes influence the development of antisocial behaviors, environment plays an even larger role. Like so many areas of medicine where the question of causality is contested between genetic and environmental influences, it appears that the answer is far from simple, and is reflective of the old psychiatric dictum that while the genetics loads the gun, the environment pulls the trigger.
So next time you are asked by two lawyers why a child does some attention grabbing antisocial act, you can list out all of the risk factors for antisocial behavior we have discussed here, or tell them it is not as simple as one or the other. Whatever your answer, I think it is incumbent on us as child and adolescent psychiatrists to do something to help change the trajectory of these children and limit their future antisocial acts. There are several programs and interventions that have rigorous studies demonstrating reductions in antisocial behavior, that could be implemented if we but had the social will. After all they could grow up and be lawyers…(this is a joke, some of my favorite relatives are lawyers).
(Mike is a Child and Adolescent and Forensic Psychiatrist who works in Juvenile Forensics for the County of San Diego. He also has a private practice in the southern part of Orange County.)
CalACAP News
New legislation, new ideas from the around the state, and a report from the lobbyist
The Organization:
CalACAP has made tremendous strides the past few months; the lobbyist has been hired, the web site is done and operational, many of the committees are meeting via teleconferences, and the executive committee is now able to think about how to use its influence in Sacramento rather than focus on internal housekeeping.
Lobbyist Report:
Tom Riley has written multiple informative reports that appear on the CalACAP website (www.calacap.org). He writes a blog about legislative activities in the state and has identified the top 12 bills of interest for child and adolescent psychiatrists. He and Cal ACAP President, Basil Bernstein are making trips to the local ROCAPS to introduce Tom, introduce the process of being involved in the legislative process, and to learn about the interests and concerns of each ROCAP.
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Legislation Report:
This report can be found on the website for CalACAP
CalACAP Representatives:
President- Basil Bernstein, MD
Northern California ROCAP delegate- Roger Wu, MD
Southern California ROCAP delegate- Bill Arroyo, MD
Central California ROCAP delegate- Stewart Teal, MD
SD ACAP delegate- Michael Tramell, MD
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Check out Cal-ACAP news at: www.calacap.org
Upcoming Events- If you have an event you would like us to help publicize, contact us via email at sandiegoacap@yahoo.com
About Our Organization…
The San Diego Academy of Child and Adolescent Psychiatry (SDACAP) is the local professional organization for child and adolescent psychiatrists who are members of the American Academy of Child and Adolescent Psychiatry (AACAP), the national organization of child and adolescent psychiatrists. SDACAP is involved in educating its members, representing the members in local, state, and national activities, and offers an opportunity to learn about and participate in community activities that relate to child and adolescent health, education, and welfare.
SDACAP makes up ¼ of the membership of the California Academy of Child and Adolescent Psychiatry (CalACAP). The other members are the Southern California, the Northern California, and the Central California Regional Organizations of Child and Adolescent Psychiatry. CalACAP represents its members in the California State Legislative, state-wide issues, and national issues as representatives from both the local and the state organizations participate in meetings hosted by AACAP.
