Kenneth Walter

A patient goes to his primary care physician for an illness.

 That screening leads to a psychiatrist referral, and that referral leads to counseling, maybe treatment. He and his psychiatrist have their pick now from cognitive behavioral therapy (CBT) and differing classes of antidepressants.

The days of treating a patient with depression, anxiety, or PTSD with the same blanket approach are over. Since 2010, psychiatry has gradually adopted the full-service approach, reflecting the need for better mental health screening, better use of technology, and better treatment.

These needs come from more frequent and more concerning reports on the growing burden and reach of mental health disorders in the US. But the resolution started in the most singular setting of healthcare.

“We've had success with depression and anxiety, and that’s because of the integration of mental health care with difficult health care, like in primary care,” Pamela Lusk, DNP, RN, PHMNP-BC, told 

. “Somebody will now be screened at least once a year.”

Lusk, a clinical associate professor at the Ohio State University College of Nursing and a Child and Adolescent Psychiatrist for Ponderosa Pediatrics, explained in an interview with 

that starting screenings at the primary care level has made a major difference in treating patients.

Most primary care practices use either the Patient Health Questionnaire-2 (PHQ-2) or the PHQ-9 to screen for depression regularly, as part of their electronic health record driver. By conducting more screenings in primary care, the practitioner can realize the issues and discuss with the patient the appropriate next steps.

One of the reasons for the better synergy between psychiatry and neurology is that different imaging technologies like functional MRIs have come to play a bigger role in finding different patterns that could equate to different psychological disorders.

While a screening cannot replace the diagnostic expertise of a doctor, Lenard Adler, MD, the director of the Adult ADHD Program and professor in the Department of Psychiatry at NYU Langone Health, 

there have been significant improvements in screening for mental health disorders, including a new depression screener commonly used in primary care settings.

Once a patient is properly screened in a primary care setting, they generally must see a specialists who can develop a treatment plan based on that individual’s needs.

Rather than strictly relying on drugs like antidepressants, there are now more and more different types of non-pharmacologic therapies available to help the patients.

Lusk explained that there is strong research-based evidence showing  the benefits of therapies like mindfulness-based stress reduction, an eight-week evidence-based program that includes intensive mindfulness training that has proven effective for patients dealing with stress, anxiety, depression, and trouble with pain.

Another approach that has emerged since 2010 is eye movement desensitization and reprocessing (EMDR) therapy for trauma. This psychotherapy is an eight-phase treatment that helps patients tap into and process emotions.

These types of therapies are particularly effective when treating different types of trauma, where researchers have long suggested taking an individualized approach to treating patients suffering from PTSD and other forms of trauma.

Indeed, psychiatric treatment should and does differ based on the age, gender, and type of trauma the person is suffering from, Charles Marmar, MD, chair of the Department of Psychiatry and Director of the PTSD Research Program at NYU Langone Health, 

“So fundamentally, the approaches we take to single-event trauma—which occurs among otherwise healthy adults who have had an accident or an assault or a recent severe exposure to a life-threatening disaster event or terrorism, who were previously highly functioning before&mdash;are usually time-limited,” Marmar said.

Marmar noted they often emphasize practical, short-term CBT, focused on activating memories of the trauma to initiate the healing process.

While these other types of therapies have proven effective, CBT is often touted as a goal-oriented therapy involving a more hands-on, problem-solving approach. It is still one of the most common and effective types of therapies for treating disorders like depression and anxiety.

With psychotherapy becoming increasingly non-pharmacological in recent years, investigators have studied how these types of therapies are effective and safe when they are combined with antidepressant drugs.

Earlier this year, in a phase 2 randomized trial, which included 292 patients with major depressive disorder (MDD), investigators found that maintenance monotherapy was associated with reduced rates of depressive recurrence, but when CBT was provided in the absence of monotherapy, a preventative effect on depressive relapse was found.

The investigators found that those withdrawing from antidepressant medications were linked to higher rates of recurrence than those with maintenance of antidepressant medication treatment, regardless of whether patients achieved recovery with or without acute cognitive behavioral therapy treatment.

Previous research has demonstrated that antidepressant medications and CBT have similar efficacies on acute outcomes for patients with MDD. The combination of the 2 forms of treatment is linked with better acute outcomes than either treatment modality alone.

With new technologies and a bigger emphasis on primary care screenings in place, the industry must always adapt and change their guidelines to reflect the current reality.

Lusk noted the advent of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which is published by the American Psychiatric Association in 2013—13 years following the publishing of DSM-IV-TR.

A major impact to come from DSM-5’s rulings, versus other iterations, is its distinctions between trauma and stress-related disorders from anxiety disorders. The guide also eliminated the multi-axial system for psychiatric assessment and organization of biopsychosocial information, and contains reclassifications of many disorders that reflect a better understanding of current clinical knowledge.

In DSM-5, 6 classes were added and 4 were removed, enabling numerous individual disorders were reclassified from one class to another. Its new distinctions for diseases including mood disorders, bipolar and related disorders, and depressive conditions help shape a new understanding of the individualized patient.

Greater needs linger. Marmar noted there are still few longer-term therapies available to patients—even combinations of behavioral therapy and medication has not been testing into the years a patient would theoretically rely upon them both.

There’s also a lot more research and discussion to come for ketamine, transcranial magnetic stimulation, and cannabidiol—each themselves a fodder for a psychiatry treatment debate.

But, even in the wake of analyses showing the 21

 century is more strife with suicides today than it was before, the tools are in place—and to be used at the right time. It’s no longer on the patient to understand what help they need.

For now, it’s as simple as going to a primary care physician for an illness, and then the process can begin.

Articles

By screening during primary care visits, patients are now more aware than ever about their possibility of depression and other mental health disorders.

Psychiatry Becomes Individual with Better Screening, More Therapies

 struggle with exercise, a physical activity regimen along with vitamin D supplementation could be beneficial.

A team, led by Neide AP Nascimento, division of geriatric and gerontology at the Federal University of São Paulo in Brazil, analyzed the data from 345 geriatric women at least 60 years old who regularly exercise at the Social Service of Commerce Santana, Community Center in order to learn the effect of 25(OH)D supplementation along with physical exercise in an interventional study.

There is substantial evidence that serum 25(OH)D concentrations greater than 25-30 nmol/L should be avoided for all age groups.

In general, a 25(OH)D level of less than 20 ng/mL has been associated with neuromuscular performance issues in elderly people including poor physical performance, low muscular strength, and muscle weakness, suggesting that vitamin D supplementation is beneficial for geriatric adults.

A vitamin D deficiency is linked to proximal myopathy observed by the atrophy of type II muscle fibers, which can have a negative effect on neuromuscular performance and can contribute to osteopenia and osteoporosis by increasing parathyroid hormone (PTH) concentrations and bone turnover.

Several epidemiological studies have analyzed lower extremity function by testing performance during long walks among older adults with lower vitamin D levels.

Physical exercises are highly effective in slowing down muscle wasting and the loss of function, but elderly patients find it difficult to exercise enough to prevent these changes. There has not been a previous study analyzing the relationship between 25(OH)D supplementation, different modalities of physical exercise, and its neuromuscular effects.  

The study included 146 geriatric women in an aquatic training program, 99 elderly women in a multifunctional fitness program, and 100 community-dwelling elderly women who had not been exercising for the last year as a control group.

The participants were asked to discontinue the use of vitamin D supplements 2 months prior to the initiation of the supplementation protocol of the study.

Each group was administered 1 cholecalciferol bottle if the participant had 25(OH)D levels below the median level. They were also instructed to consume 21,000 IU per week—4 drops per week&mdash;of cholecalciferol for 12 months.

The investigators also administered a series of physical tests for the participants, including a timed up-and-go (TUG)test, a 2-min step (2-MST), a 30-second chair stand (CS), functional reach (FRT), unipedal balance test with visual control (UB), and a portable dynamometer for the strength of hip flexors (HS).  They also measured the serum 25(OH)D and intact parathyroid hormone levels at the beginning and conclusion of the 12-month study.

They compared the treatments using a general linear model for repeated measures (

“There was a significant increase in 25(OH)D levels in ATSG (

 < .001),” the authors wrote. “The relationship between 25(OH)D levels and physical exercise was significant in TUG (

Effect of Vitamin D Level and Physical Exercise on the Physical Performance and Functional Test Results in Elderly Women

Journal of Geriatric Medicine and Gerontology

In an intervention study, investigators try to show whether vitamin D deficiency interferes with slowing muscle wasting and losing function in geriatric adults.

Vitamin D, Exercise Combination Helps Geriatrics Maintain Muscle Mass, Function

With the US Food and Drug Administration (FDA) awarding dapagliflozin (Farxiga) their Fast Track designating, investigators spoke in favor of the drug to reduce the risk of heart failure for adults with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF).

A pair of successful phase 3 clinical trials--DAPA-HF and DELIVER—revealed the safety in reducing heart failure or cardiovascular death for these patients.

Heart Failure Society of America (HFSA) 2019 Scientific Sessions

 in Philadelphia, PA, John McMurray, MD, University of Glasgow, who was a researcher with the DAPA-HF trial, explained in an interview with 

that the success of the trial could yield a bright future for dapagliflozin.

 What we wanted to study in our trial whether these drugs could be used as a treatment for patients with established heart failure. Not only that but we wanted to also ask the question whether these drugs could be beneficial in heart failure patients who do not have diabetes because there is experimental evidence that suggests that SGLT2 inhibitors may have benefits that are not glucose depend. So, to do this, we studied heart failure and reduced ejection fraction receiving conventional therapy who were randomized to either 10 mg of dapagliflozin daily or a placebo

On the results of the dapagliflozin study.

For that primary endpoint, we found that dapagliflozin reduced the risk by 26% and that was highly statistically significant. Both of the components of the endpoint were also reduced so there was a 30% reduction in the risk of worsening heart failure events and that was statistically significant and there was an 18% reduction in the risk of cardiovascular mortality and that was also statistically significant.

On the patients self-reporting symptoms during the trial. 

We had a number of secondary outcomes, but I already just mention 1 of those that's important we also looked at issues self-reported symptoms using the Kansas City Cardiomyopathy Questionnaire and what we find with that questionnaire is

that more people in the dapagliflozin group reported an improvement of symptoms and significantly fewer people in the dapagliflozin group reported a deterioration or worsening of symptoms.

So, in summary what we found was dapagliflozin does what really want any drug to do. It improves symptoms, it improves survival and it reduced hospital admission. It did that in all the important subgroups that we looked at including patients who didn't diabetes, the risk reductions both in relative terms and absolute terms were quite substantial and dapagliflozin was very well tolerated. So, in conclusion we really thought that we've shown that dapagliflozin is a potentially valuable new addition to the drugs that we have treat heart failure with reduced rejection fraction.

After success in a recent clinical trial, dapagliflozin will soon be available to reduce the risk of heart failure in adults with heart failure reduced ejection fraction or preserved ejection fraction.

John McMurray, MD: The Future is Bright for Dapagliflozin

Finding the right diet can be a daunting task, especially for 

 in Philadelphia, PA, Amanda Vest, MBBS, MPH, Tufts Medical Center, presented a new nutritional guideline for heart failure patients that focuses on dietary composition and counseling, obesity management, and cachexia malnutrition.

“So, the concept of food as medicine has gotten momentum lately that leveraging the diet to prevent or treat heart failure remains in my opinion a missed opportunity for so many of our patients with heart failure,” Vest said. “Given the lack of detailed nutrition recommendations and existing heart failure guidelines, I recently led a multi-disciplinary writing group several times a day, including cardiologists, dietitians, nurses and pharmacists to assemble a consensus statement on nutrition for patients with heart failure.”

Vest said some of the popular diets that would be good for heart failure patients would be the DASH or Mediterranean diet, as well as plant-based diets. Vest also acknowledged ongoing randomized trials on the optimal sodium intake, but for the time being it is recommended limiting sodium to 2-3 grams per day for heart failure patients.

She also said bariatric surgery should be considered for all eligible patients, which has been shown retrospectively in several different cohorts to cut the risk of incident heart failure in half.

Vest explained that while the guidelines suggest replacing saturated fats with modern polyunsaturated fats such as olive oil and fish oil, there are no longer specified limits on saturated fats. They also do not include a specific sodium limit, but suggest limiting processed meats, refined carbohydrates and sweetened beverages and strongly recommend against the consumption of any trans fats.

The guidelines recommend that patients with heart failure and the body mass index of 35 or above receive counseling on a calorie restricted diet that aims for 5-10% weight loss.

Vest said dietary consultation is a key tenant in the new recommendations.

“And it just contains a lot of recommendations for all patients with heart failure to receive a 30 to 60-minute dietician consultation with a follow up encounter in 4 to 6 weeks,” Vest said.

Vest explained that the government’s mind plate approach to diet, which includes suggestions on healthy dietary composition and appropriate portion sizes, was created using controversial evidence, leading to other guides emerging.

“And so, for example, the Harvard School of Public Health has released its own edited version that replaces the milk with a water as a preferred beverage, and also adds a serving of healthy fat,” she said.  “The 2019 [American College of Cardiology/American Heart Association] Primary Prevention Guidelines about data the concept of a heart healthy diet is the most recent evidence from epidemiological data.

“These guidelines emphasize the diet rich in fruits, vegetables, legumes, nuts, whole grains and fish, due to the associations between these foods and lower rates of atherosclerosis, muscular disease.”

At the annual meeting dedicated to heart failure, investigators present nutritional recommendations for patients, which includes dietary consultations, bariatric surgery, and a reduction in saturated fats and sodium.