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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_405"
                     title="Difficult Childhood Lingers in the Mind (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18312?impressionId=1265772081517"
                     
      &lt;p&gt;Adversities faced in childhood have effects on mental health far into the future, researchers affirmed.&lt;/p&gt;
&lt;p&gt;Mental illness in adulthood was increasingly likely the more traumas faced in childhood, Ronald C. Kessler, PhD, of Harvard, and colleagues reported in the February issue of the &lt;em&gt;Archives of General Psychiatry&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Childhood difficulties potentially explained 32.4% of all the psychiatric disorders examined, they said, based on analyses of the National Comorbidity Survey Replication.&lt;/p&gt;
&lt;p&gt;Adversities relating to family dysfunction  --  substance-abusing parents, sexual or physical abuse in the home, neglect, etc.  --  appeared to have the strongest link to onset and persistence of psychiatric disorders, they reported.&lt;/p&gt;
&lt;p&gt;These findings match folk wisdom and decades of research into the negative effects of child maltreatment, commented John McGrath, MD, PhD, of the Queensland Centre for Mental Health Research in Wacol, Australia, and colleagues in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;But the lack of specificity between certain exposures to particular mental health outcomes  --  such as the death of one&apos;s mother leading to depression  --  was notable, the editorialists said.&lt;/p&gt;
&lt;p&gt;&quot;Thus, childhood trauma upsets the orderly psychological and biological cascades of development, leaving the affected individual at increased risk of a wide range of adverse mental health outcomes,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Rather than continue to rehash the epidemiology, it&apos;s time to focus on prevention and intervention, McGrath&apos;s group emphasized.&lt;/p&gt;
&lt;p&gt;&quot;It is unrealistic to think that we could protect all children from all adversities, but can we identify factors that bolster resilience and focus our efforts on the most vulnerable subgroups?&quot; they asked.&lt;/p&gt;
&lt;p&gt;The researchers examined joint associations of 12 retrospectively reported childhood adversities with lifetime incidence of disorders meeting Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria in the National Comorbidity Survey Replication I, a cross-sectional survey of a nationally-representative sample of adults in 9,282 American households.&lt;/p&gt;
&lt;p&gt;Among the respondents, 53.4% reported at least one childhood adversity, most commonly parental divorce (17.5%), family violence (14.0%), family economic problems (10.6%), and parental mental illness (10.3%).&lt;/p&gt;
&lt;p&gt;These adversities were all individually and significantly linked to first onset of psychiatric disorders with odds ratios of 1.5 to 1.9 for dysfunctional family factors (physical abuse, sexual abuse, neglect, parental mental illness, parental substance abuse, parental criminality, or family violence) and 1.0 to 1.5 for other factors like life-threatening childhood physical illness, extreme poverty, parental divorce, or loss of or separation from parents.&lt;/p&gt;
&lt;p&gt;Despite some apparent but not significantly meaningful variation in type of adversity with type of psychiatric disorder, the researchers said they could rule out that all types were the same for future mental health risk (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Problems tended to cluster, though. Among people who faced one adversity in childhood, 51.2% to 95.1% faced others as well, depending on the adversity.&lt;/p&gt;
&lt;p&gt;Risk of mental illness rose with number of issues faced in childhood from an odds ratio of 1.3 for one up to 3.4 for six and 3.2 for seven or more adversities.&lt;/p&gt;
&lt;p&gt;&quot;This subadditive pattern has important implications for intervention because it means that prevention or amelioration of only a single childhood adversity in youths exposed to many childhood adversities is unlikely to have important preventive effects,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Overall, childhood adversities were projected to account for 44.6% of childhood-onset disorders, 32.0% of adolescent-onset disorders, and 28.6% of adult-onset disorders.&lt;/p&gt;
&lt;p&gt;The researchers also looked at persistence through the second part of the National Comorbidity Survey Replication which went beyond just core diagnostic assessment in 5,692 respondents.&lt;/p&gt;
&lt;p&gt;In a complex multivariate interactive analysis, childhood adversity from dysfunctional family factors appeared significantly linked to persistence in a given year (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) whereas the number of factors was not significant.&lt;/p&gt;
&lt;p&gt;These significant factors were parental mental illness, physical abuse, sexual abuse, and neglect, but they carried modest effects individually with odds ratios of 1.2.&lt;/p&gt;
&lt;p&gt;But in one simulation, not being exposed to childhood trauma would only increase the time since the most recent episode of psychiatric illness by 1.6%, suggesting &quot;quite modest&quot; substantive importance in determining persistence.&lt;/p&gt;
&lt;p&gt;&quot;These results indirectly suggest that the public health implications of childhood adversities are greater for primary than for secondary prevention because the associations of childhood adversities with disorder onset are much stronger than the associations with persistence,&quot; Kessler&apos;s group wrote.&lt;/p&gt;
&lt;p&gt;The researchers cautioned that recall bias may have limited their study such that the results could be considered an &quot;upper bound&quot; for the real association and that the study could not prove causality.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Comorbidity Survey Replication is supported by a grant from the National Institute of Mental Health with supplemental support from the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, a grant from the Robert Wood Johnson Foundation, and the John W. Alden Trust.&lt;/p&gt;&lt;p&gt;The analyses were supported by a grant from the NIMH; the John D. and Catherine T. MacArthur Foundation; the Pfizer Foundation; grants from the U.S. Public Health Service; an award from the Fogarty International Center; the Pan American Health Organization; Eli Lilly; Ortho-McNeil Pharmaceutical; GlaxoSmithKline; and Bristol-Myers Squibb.&lt;/p&gt;&lt;p&gt;Kessler reported financial conflicts of interest with GlaxoSmithKline, Kaiser Permanente, Pfizer, sanofi-aventis, Shire Pharmaceuticals, Wyeth-Ayerst, Eli Lilly, Bristol-Myers Squibb, Johnson &amp;amp; Johnson Pharmaceuticals, and Ortho-McNeil Pharmaceutical.&lt;/p&gt;&lt;p&gt;The editorialists reported no conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_369"
                     title="Administration Issues Mental Health Parity Rule"
                     score="0.009"
                     href="http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/tb/18258?impressionId=1265772081517"
                     
      &lt;p&gt;WASHINGTON  --  Under a proposed rule released by the Obama administration, patients in a group insurance plan who are being treated for mental illness or substance abuse may no longer be charged more than if they were receiving medical or surgical care.&lt;/p&gt;
&lt;p&gt;The Department of Health and Human Service (HHS), the Department of Labor, and the Internal Revenue Service issued an interim rule last week containing specific language necessary to enforce the bipartisan &lt;a href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/11169&quot; mce_href=&quot;http://www.medpagetoday.com/Psychiatry/GeneralPsychiatry/11169&quot; target=&quot;_blank&quot; title=&quot;Financial&amp;#8200;Bailout&amp;#8200;Carries&amp;#8200;Mental&amp;#8200;Health&amp;#8200;Parity&amp;#8200;Bill&amp;#8200;Through&amp;#8200;Congress&quot;&gt;mental health parity law passed by Congress in 2008&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;The law  --  called the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act  --  states that if a group health plan covers the treatment of mental illness or drug or alcohol abuse, the limits and financial requirements for these services can be &quot;no more restrictive&quot; than those that apply to medical and surgical benefits.&lt;/p&gt;
&lt;p&gt;That means an insurance plan cannot charge higher copayments, deductibles, and out-of-pocket expenses for mental health services than for treatment of physical illnesses.&lt;/p&gt;
&lt;p&gt;Companies with fewer than 50 employees in their group insurance plans are excluded from the law.&lt;/p&gt;
&lt;p&gt;&quot;The rules we are issuing today will, for the first time, help assure that those diagnosed with these debilitating and sometimes life-threatening disorders will not suffer needless or arbitrary limits on their care,&quot; said Kathleen Sebelius, secretary of HHS.&lt;/p&gt;

&lt;p&gt;The American Psychiatric Association (APA) issued a statement applauding the regulations.&lt;/p&gt;
    &lt;p&gt;&quot;Mental health parity was a major advance for the APA and for our patients living with mental illnesses,&quot; according to the group&apos;s president, Alan F. Schatzberg, MD. &quot;The APA will continue to work hard and submit the important feedback to the administration that is necessary to make sure our patients receive the care they need.&quot;&lt;/p&gt;
    &lt;p&gt;The statement also drew attention to some shortcomings in the regulations, which did not address provider networks and formulary development.&lt;/p&gt;
    &lt;p&gt;The APA intends to submit recommendations for these and other topics during the 90-day comment period.&lt;/p&gt;
    &lt;p&gt;The American Psychological Association also welcomed the regulations.&lt;/p&gt;
    &lt;p&gt;&quot;We are delighted that under these regulations consumers are protected from insurance discrimination to the greatest extent possible,&quot; according to its executive director for professional practice, Katherine Nordal, PhD, in a prepared statement.&lt;/p&gt;
    &lt;p&gt;The rule also requires a single deductible for mental health and medical/surgical coverage. Patients who are being treated for a mental condition at the same time as somatic condition often have to pay separate deductibles which can &quot;prevent access to mental health treatment,&quot; according to the psychologists&apos; group.&lt;/p&gt;
    &lt;p&gt;&quot;It is particularly significant that the regulation will ban health plans from imposing separate deductibles or setting separate out-of-pocket caps for mental health and medical/surgical services,&quot; the statement said. &quot;This is a big win for anyone seeking mental health treatment.&quot;&lt;/p&gt;
    &lt;p&gt;The 2008 law expanded greatly on the Mental Health Parity Act of 1996, which required parity only in lifetime and annual dollar limits. In practice, crtics say, insurers got around that prohibition by charging higher copayments for mental health services and by &quot;cherry-picking&quot; services that would and would not be covered.&lt;/p&gt;
    &lt;p&gt;The 1996 law also specifically excluded coverage parity for substance abuse treatment.&lt;/p&gt;
    &lt;p&gt;The new rule will take effect April 5, 2010.

    </recommendedItem>
    <recommendedItem id="20100101_19_245"
                     title="Accidents, Illness Cause Most War-Zone Casualties (CME/CE)"
                     score="0.001"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/18100?impressionId=1265772081517"
                     
      &lt;p&gt;More than 85% of American military medical evacuations from the Middle East were not the direct result of enemy action, but the result of non-battle injuries and disease, researchers said.&lt;/p&gt;
&lt;p&gt;Of some 34,000 military personnel in Iraq and Afghanistan who shipped out for medical reasons from 2004 to 2007, only 14% had been wounded or injured in combat, according to Steven P. Cohen, MD, of Johns Hopkins, and colleagues.&lt;/p&gt;
&lt;p&gt;The most common reasons for medical evacuation were non-battle related musculoskeletal and connective tissue disorders, accounting for 24% of evacuations, the researchers wrote in the Jan. 23 issue of &lt;em&gt;The Lancet&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Combat injuries were the second most common, followed by neurological disorders (10%) and psychiatric illnesses (9%).&lt;/p&gt;
&lt;p&gt;&quot;Non-battle related injuries continue to be the leading cause of medical evacuation in modern warfare, and medical officers should be prepared for this burden in subsequent conflicts,&quot; Cohen and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;To reduce the number of evacuees, preventive medicine programmes and educational initiatives need to target health-care providers, non-commissioned officers, and combat soldiers.&quot;&lt;/p&gt;
&lt;p&gt;They also warned that &quot;the burden of psychiatric illness&quot; will increase with the duration of conflict and reliance on reserve units.&lt;/p&gt;
&lt;p&gt;Cohen and colleagues obtained data kept by the U.S. military on all medical evacuations from Iraq and Afghanistan spanning 2004 to 2007.&lt;/p&gt;
&lt;p&gt;In addition to describing the medical reasons for evacuation, the data included the individuals&apos; ranks, service affiliations, active-duty or reserve status, and whether personnel returned to duty.&lt;/p&gt;
&lt;p&gt;Any injury sustained during combat missions, including those not caused directly by enemy fire such as back strains, was counted as battle-related.&lt;/p&gt;
&lt;p&gt;The number of evacuations each year fell from 2004 to 2006  --  from 10,290 to 6,778  --  but abruptly rose in 2007 to 8,444 with the Iraq surge and the reinvigorated Afghan Taliban resistance.&lt;/p&gt;
&lt;p&gt;Not surprisingly, as these conflicts evolved over time, the balance of combat and non-combat injuries and illnesses changed and the characteristics of evacuated soldiers changed as well.&lt;/p&gt;
&lt;p&gt;The proportion of evacuations related to combat injuries climbed steadily in Afghanistan, from 10% in 2004 to 19% in 2007. Injuries from combat also increased over time in Iraq but not as much: from 24% of evacuations to 28% during the study period.&lt;/p&gt;
&lt;p&gt;But by 2007, combat wounds had become only the fourth most common reason for evacuation in both regions.&lt;/p&gt;
&lt;p&gt;Musculoskeletal and connective tissue disorders held steadily as the number one reason throughout the study period, ranging from 21% to 28%.&lt;/p&gt;
&lt;p&gt;But non-combat neurological and psychiatric disorders both increased substantially, especially the latter.&lt;/p&gt;
&lt;p&gt;Evacuations for psychiatric conditions soared from 5% to 6% of the total in 2004 to about 13% in 2007. Neurological disorders accounted for about 10% of evacuations early in the conflicts, rising to more than 12% in 2007. These figures did not differ substantially between Iraq and Afghanistan.&lt;/p&gt;
&lt;p&gt;Most of the evacuees did not return to duty: about 80% of those shipped from Iraq and 75% from Afghanistan.&lt;/p&gt;
&lt;p&gt;Although overall return-to-duty rates changed little with time, evacuations for some types of illness did increase or decrease.&lt;/p&gt;
&lt;p&gt;Personnel evacuated because of infectious disease became more likely to see service again  --  37% returned to active duty in 2007, compared with 8% in 2004. Cohen and colleagues identified better control of leishmaniasis as at least partly responsible for the increase.&lt;/p&gt;
&lt;p&gt;More significantly, the researchers indicated, return-to-duty rates declined progressively after 2004 for psychiatric evacuees, Cohen and colleagues reported.&lt;/p&gt;
&lt;p&gt;By 2007, only 7% of psychiatric evacuees from Iraq and 4% of those from Afghanistan were returning to duty.&lt;/p&gt;
&lt;p&gt;The researchers also found that, among particular types of psychiatric illness, personnel with stress reactions, depression, and bipolar disorder were least likely to return to duty.&lt;/p&gt;
&lt;p&gt;They also found that individuals with back pain were also more unlikely than most evacuees to return to duty.&lt;/p&gt;
&lt;p&gt;In their report, Cohen and colleagues said these latter trends were potentially related.&lt;/p&gt;
&lt;p&gt;&quot;The parallels between emotional distress and spinal pain are intriguing. Findings from several studies in patients presenting with back or neck pain have established that the major risk factors for disability and persistence are psychosocial (e.g., anxiety, depression, poor coping skills, and low job satisfaction),&quot; they wrote.&lt;/p&gt;
&lt;p&gt;&quot;As survival rates of combat injuries increase, and the burden of non-battle-related injuries and psychiatric disorders continues to soar, society must be prepared to deal with the aftermath of these injuries,&quot; Cohen and colleagues concluded.&lt;/p&gt;
&lt;p&gt;In an accompanying commentary, J. Don Richardson, MD, of St. Joseph&apos;s Health Care in London, Ontario, and colleagues also found the results on psychiatric evacuees most striking in the study.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty in service personnel evacuated for psychiatric conditions warrants further study, and [the] article points out the importance of cumulative stress in repeated deployments and the physical and mental demands on the military member and their family,&quot; Richardson and colleagues wrote.&lt;/p&gt;
&lt;p&gt;&quot;The low rate of return to duty might be related to the nature of the combat operation for which military commanders might be reluctant to deploy an individual with a psychiatric diagnosis to a combat zone,&quot; they speculated.&lt;/p&gt;
&lt;p&gt;&quot;Early intervention becomes crucial to help promote recovery because military members often experience substantial stigma disclosing symptoms of PTSD and other psychiatric problems,&quot; Richardson and colleagues added.&lt;/p&gt;
&lt;p&gt;They also suggested that military doctors &quot;should have a high index of suspicion&quot; for PTSD when soldiers present with spinal pain or other somatic complaints, &quot;especially if there is a physical injury.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the federally funded John P. Murtha Neuroscience and Pain Institute and the U.S. Army.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported by study authors or the editorialists.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_124"
                     title="Morphine Cuts Both Pain and PTSD (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/MilitaryMedicine/tb/17938?impressionId=1265772081517"
                     
      The use of morphine may prevent the development of post-traumatic stress disorder (PTSD) in military personnel injured in combat, an observational study showed.&lt;br&gt;
&lt;br&gt;Those who received the drug during resuscitation or trauma care were about half as likely to later develop PTSD (OR 0.47, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Troy Lisa Holbrook, PhD, of the Naval Health Research Center in San Diego, and colleagues.&lt;br&gt;
&lt;br&gt;&quot;Our findings suggest that the use of morphine after serious injury may be a first-line defense against the development of PTSD,&quot; they wrote in the Jan. 14 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;They said that any benefits, if causal, would likely be seen with other opiates as well.&lt;/p&gt;
&lt;p&gt;Previous studies have found that pharmacotherapy following trauma may be effective for secondary prevention of PTSD, with the primary goal of interfering with memory consolidation and the associated conditioned response to fear, according to the researchers.&lt;/p&gt;
&lt;p&gt;And a small study found a protective effect from morphine specifically in children with burn injuries.&lt;/p&gt;
&lt;p&gt;To evaluate the drug&apos;s effect in adults, Holbrook and her colleagues turned to a U.S. Navy-Marine Corps combat trauma database that included information on medications administered after injury.&lt;/p&gt;
&lt;p&gt;They analyzed data for 696 military personnel who were hurt during Operation Iraqi Freedom but who did not have serious traumatic brain injury.&lt;/p&gt;
&lt;p&gt;Nearly all of the injured personnel were male and the mean age was about 24.&lt;/p&gt;
&lt;p&gt;The most common mechanisms of injury were improvised explosive devices, gunshots, mortar fire, and rocket-propelled grenades.&lt;/p&gt;
&lt;p&gt;About one-third (35%) of the injured personnel developed PTSD. Those who did were less likely to have been administered morphine shortly after their injury (60% versus 76%).&lt;/p&gt;
&lt;p&gt;The use of morphine was associated with a significantly lower risk of PTSD (ORs ranging from 0.48 to 0.66, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05 for all) in models adjusting for several factors, including severity and mechanism of injury, need for amputation, resuscitation, and the presence of mild traumatic brain injury.&lt;/p&gt;
&lt;p&gt;Morphine dose had no effect on the relationship.&lt;/p&gt;
&lt;p&gt;Although causality could not be established, any beneficial effect morphine might have on PTSD risk might involve pain reduction; previous studies have identified associations between lower pain levels after serious injury and a reduced risk of developing the disorder.&lt;/p&gt;
&lt;p&gt;&quot;The logical conclusion to be made on the basis of these data is that a reduction in perceived pain levels through the use of morphine or other opiates as part of trauma care may lower the rate of PTSD onset after major trauma,&quot; Holbrook and her colleagues wrote.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Matthew Friedman, MD, PhD, of the National Center for PTSD at the VA Medical Center in White River Junction, Vt., said, &quot;This finding adds to a small but growing body of observational and experimental studies that have reported similar results.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Since physical injury from a traumatic event (especially injury that is associated with severe pain) is a risk factor for the later development of PTSD, such findings suggest a potential for prophylactic use of rapid pain reduction among injured, traumatized persons in both military and civilian acute care settings,&quot; he said.&lt;/p&gt;
&lt;p&gt;He noted, however, that use of opioids would likely not be an acceptable treatment for individuals exposed to trauma who had not suffered major, painful injuries.&lt;/p&gt;
&lt;p&gt;The findings of the current study, he wrote in his editorial, are consistent with theories about the adrenergic mediation of fear-conditioned traumatic memories.&lt;/p&gt;
&lt;p&gt;&quot;These results should motivate researchers to redouble efforts to test adrenergic antagonists such as propranolol and clonidine (an &amp;#945;&lt;sub&gt;2&lt;/sub&gt;-adrenergic agonist) in the search for a morning-after pill to prevent the later development of PTSD among persons after major trauma.&quot;&lt;/p&gt;
&lt;p&gt;Holbrook and her colleagues acknowledged that the study was limited by its observational design, missing or incomplete data on medication for patients who were ultimately excluded from the study, and the inability to thoroughly address the question of a dose-response relationship.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the U.S. Navy Bureau of Medicine and Surgery under the Wounded, Ill, and Injured-Psychological Health-Traumatic Brain Injury Program.&lt;/p&gt;&lt;p&gt;Neither the study authors nor the editorialist reported any conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_5_377"
                     title="PTSD Increases Hospitalization Rates in Urban Poor"
                     score="-0.005"
                     href="