American College Of Psychiatrists Meeting

SAN ANTONIO – The American Medical Association is working toward numerous goals that stand to improve health care and the practice of medicine, including some that target issues of particular concern to psychiatrists, according to Dr. Jeremy A. Lazarus.

In general, the efforts aim to enhance professional satisfaction for physicians, improve outcomes for patients, and transform medical education to make sure that current medical students are prepared to practice 21st century medicine, Dr. Lazarus of the University of Colorado Denver and immediate past president of the AMA at said at the annual meeting of the American College of Psychiatrists.

During an update on the AMA’s efforts, Dr. Lazarus described several recent activities and successes, and reflected on the "tremendous partnership that the AMA has with psychiatry and the (American Psychiatric Association).""We have a long history of fighting together," he said, referring to successes such as the decade-long effort that resulted in getting the mental health parity bill passed, the joining together of more than 80 state and specialty societies to address and combat efforts – like a successful effort in New Mexico in 2002 – to give prescribing privileges to psychologists, and – recently – participation in the Joining Forces initiative to ensure that veterans with posttraumatic stress disorder, post-combat depression, or traumatic brain injury receive the care and resources they need.

Other recent AMA activities and successes outlined by Dr. Lazarus include:

• Testifying to the U.S. Senate regarding the Sunshine Act provisions of the Affordable Care Act.

Dr. Lazarus said he voiced the AMA’s support for transparency, but cautioned that physicians need to have the right to review reported information to ensure accuracy.

The AMA is committed to making sure that "the powers that be in Washington, D.C., hear physicians’ concerns loud and clear," he said.

• Working with state medical societies and associations on numerous legislative issues that affect physicians and health care.

"The AMA achieved many legislative victories in 2012-2013, including truth-in-advertising legislation, preserving existing medical liability reforms, protecting the patient-physician relationship, and also turning back and defeating many scope of practice expansions," he said.

For example, in conjunction with 10 other specialty groups, the AMA helped to overturn a Florida law that prohibited physicians from talking to patients/parents about guns in the home and gun safety, and from making any note about the conversation in patient charts.

"We feel it is imperative that lawmakers not get in the way of physician-patient communication," he said.

• Working toward Medicare reform.

Efforts toward reform have been ongoing for a decade or more, Dr. Lazarus said.

"We are close to the finish line," he noted.

Efforts to repeal the Medicare Sustainable Growth Rate formula and to move toward different systems of paying physicians continue, as scores of state and specialty societies work together to develop a system that will provide many options for payment for physicians that will reward physicians for savings in the health care system, support practice investments so that physicians can move to different forms of practicing, and tie physician payment to their own actions rather than to those of others whom they can’t control.

"We got great news on Feb. 6 – there is now joint legislation to repeal the SGR that’s advancing in both the House and the Senate," he said, noting that the impending legislation is the result of work by the AMA and other organizations working together to "keep this issue alive, to try to modify the bills as they were going through the House and the Senate, and to make sure we got to a positive outcome."

"We want the Medicare payment program to be a stable 21st-century program that can meet the growing health care needs of our senior population, and we’ve been very pleased that the committees have made many changes recommended by the AMA," he said.

The current bill under consideration – the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 – includes a repeal of the SGR formula, automatic positive payment updates of 0.5% for the next 5 years, a consolidated and simpler Medicare quality reporting program, and the ability to transition to different models of care.

"We’ve now got a March 31 deadline. If nothing is done, there will be a 24% cut in Medicare payments, so stay tuned. We’re looking for things to advance ... we haven’t been any closer than we are right now, so we’re very hopeful," he said.

Those interested in participating in the effort to reform Medicare can visit the AMA’s FixMedicareNow.org website for more information, he noted.

The efforts mentioned by Dr. Lazarus are among the matters "high on the list for AMA advocacy," but are just a small part of the AMA’s activities.

"We’re also looking at the big picture in terms of the health care system in this country to try to lead a major effort on the big issues," he said.

Among the concerns are the "tremendously overburdened system," with 50 million individuals uninsured and $2.7 trillion in annual spending (18% of gross domestic product) with outcomes that are poorer than those of other developed countries – and with an estimated increase of spending up to $4.6 trillion (20% of GDP) by 2020. The fragmented delivery system, with a lack of coordination of care and an epidemic of chronic conditions that account for 75% of the spending, also are among the concerns being addressed by the AMA.

Facing these tremendously complicated and difficult situations, the AMA decided to "take our years of training on addressing major issues, and put them to work on what amounts to an AMA policy triathlon," Dr. Lazarus said, referring to the three-pronged plan of enhancing physician satisfaction, improving health outcomes, and accelerating needed changes in medical education.

"We’ve committed to finishing this race," he said, noting that it will be a long one.

Efforts to improve care delivery models include collaboration with the RAND Corp. to conduct field research at 30 diverse practice settings across the country to identify factors associated with success and satisfaction.

Results are forthcoming, but initial findings suggest that what physicians care most about is the ability to deliver high-quality care.

The plan is to create tools to help physicians choose the best model for meeting their particular needs, and to advocate both federally and locally to promote adoption of models that improve physician and patient satisfaction, he said.

The AMA will continue to work to remove regulatory barriers that get in the way of providing quality health care, level the playing field with health insurers, help facilitate relationships with hospital and other payers to ensure a physician leadership role in emerging care models, and explore solutions to improve electronic health record platforms, he added.

As for improving health outcomes, efforts include several initiatives and partnerships designed to reduce disease burden and the cost burden associated with some of the most pervasive and troubling health conditions, such as diabetes. As for medical education, the AMA has issued $1 million in grants to 11 medical schools to advance new ways of teaching – such as through more flexible and individualized learning plans – to better prepare students for practicing in the changing health care environment.

"Just imagine the possibilities if we are even partially successful with this strategic plan – if we have increased quality of care, healthier patients, lower costs, and physicians working in a sustainable health environment that they have created themselves and that they think works for them, and if we have medical students trained for 21st-century medicine," he said. "It will take a lot of work and a lot of effort and a lot of focus, but at the end, we think there will be a healthier future for our health care system ... physicians, [and] ... our country as a whole."

SAN ANTONIO – The American Medical Association is working toward numerous goals that stand to improve health care and the practice of medicine, including some that target issues of particular concern to psychiatrists, according to Dr. Jeremy A. Lazarus.

In general, the efforts aim to enhance professional satisfaction for physicians, improve outcomes for patients, and transform medical education to make sure that current medical students are prepared to practice 21st century medicine, Dr. Lazarus of the University of Colorado Denver and immediate past president of the AMA at said at the annual meeting of the American College of Psychiatrists.

During an update on the AMA’s efforts, Dr. Lazarus described several recent activities and successes, and reflected on the "tremendous partnership that the AMA has with psychiatry and the (American Psychiatric Association).""We have a long history of fighting together," he said, referring to successes such as the decade-long effort that resulted in getting the mental health parity bill passed, the joining together of more than 80 state and specialty societies to address and combat efforts – like a successful effort in New Mexico in 2002 – to give prescribing privileges to psychologists, and – recently – participation in the Joining Forces initiative to ensure that veterans with posttraumatic stress disorder, post-combat depression, or traumatic brain injury receive the care and resources they need.

Other recent AMA activities and successes outlined by Dr. Lazarus include:

• Testifying to the U.S. Senate regarding the Sunshine Act provisions of the Affordable Care Act.

Dr. Lazarus said he voiced the AMA’s support for transparency, but cautioned that physicians need to have the right to review reported information to ensure accuracy.

The AMA is committed to making sure that "the powers that be in Washington, D.C., hear physicians’ concerns loud and clear," he said.

• Working with state medical societies and associations on numerous legislative issues that affect physicians and health care.

"The AMA achieved many legislative victories in 2012-2013, including truth-in-advertising legislation, preserving existing medical liability reforms, protecting the patient-physician relationship, and also turning back and defeating many scope of practice expansions," he said.

For example, in conjunction with 10 other specialty groups, the AMA helped to overturn a Florida law that prohibited physicians from talking to patients/parents about guns in the home and gun safety, and from making any note about the conversation in patient charts.

"We feel it is imperative that lawmakers not get in the way of physician-patient communication," he said.

• Working toward Medicare reform.

Efforts toward reform have been ongoing for a decade or more, Dr. Lazarus said.

"We are close to the finish line," he noted.

Efforts to repeal the Medicare Sustainable Growth Rate formula and to move toward different systems of paying physicians continue, as scores of state and specialty societies work together to develop a system that will provide many options for payment for physicians that will reward physicians for savings in the health care system, support practice investments so that physicians can move to different forms of practicing, and tie physician payment to their own actions rather than to those of others whom they can’t control.

"We got great news on Feb. 6 – there is now joint legislation to repeal the SGR that’s advancing in both the House and the Senate," he said, noting that the impending legislation is the result of work by the AMA and other organizations working together to "keep this issue alive, to try to modify the bills as they were going through the House and the Senate, and to make sure we got to a positive outcome."

"We want the Medicare payment program to be a stable 21st-century program that can meet the growing health care needs of our senior population, and we’ve been very pleased that the committees have made many changes recommended by the AMA," he said.

The current bill under consideration – the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 – includes a repeal of the SGR formula, automatic positive payment updates of 0.5% for the next 5 years, a consolidated and simpler Medicare quality reporting program, and the ability to transition to different models of care.

"We’ve now got a March 31 deadline. If nothing is done, there will be a 24% cut in Medicare payments, so stay tuned. We’re looking for things to advance ... we haven’t been any closer than we are right now, so we’re very hopeful," he said.

Those interested in participating in the effort to reform Medicare can visit the AMA’s FixMedicareNow.org website for more information, he noted.

The efforts mentioned by Dr. Lazarus are among the matters "high on the list for AMA advocacy," but are just a small part of the AMA’s activities.

"We’re also looking at the big picture in terms of the health care system in this country to try to lead a major effort on the big issues," he said.

Among the concerns are the "tremendously overburdened system," with 50 million individuals uninsured and $2.7 trillion in annual spending (18% of gross domestic product) with outcomes that are poorer than those of other developed countries – and with an estimated increase of spending up to $4.6 trillion (20% of GDP) by 2020. The fragmented delivery system, with a lack of coordination of care and an epidemic of chronic conditions that account for 75% of the spending, also are among the concerns being addressed by the AMA.

Facing these tremendously complicated and difficult situations, the AMA decided to "take our years of training on addressing major issues, and put them to work on what amounts to an AMA policy triathlon," Dr. Lazarus said, referring to the three-pronged plan of enhancing physician satisfaction, improving health outcomes, and accelerating needed changes in medical education.

"We’ve committed to finishing this race," he said, noting that it will be a long one.

Efforts to improve care delivery models include collaboration with the RAND Corp. to conduct field research at 30 diverse practice settings across the country to identify factors associated with success and satisfaction.

Results are forthcoming, but initial findings suggest that what physicians care most about is the ability to deliver high-quality care.

The plan is to create tools to help physicians choose the best model for meeting their particular needs, and to advocate both federally and locally to promote adoption of models that improve physician and patient satisfaction, he said.

The AMA will continue to work to remove regulatory barriers that get in the way of providing quality health care, level the playing field with health insurers, help facilitate relationships with hospital and other payers to ensure a physician leadership role in emerging care models, and explore solutions to improve electronic health record platforms, he added.

As for improving health outcomes, efforts include several initiatives and partnerships designed to reduce disease burden and the cost burden associated with some of the most pervasive and troubling health conditions, such as diabetes. As for medical education, the AMA has issued $1 million in grants to 11 medical schools to advance new ways of teaching – such as through more flexible and individualized learning plans – to better prepare students for practicing in the changing health care environment.

"Just imagine the possibilities if we are even partially successful with this strategic plan – if we have increased quality of care, healthier patients, lower costs, and physicians working in a sustainable health environment that they have created themselves and that they think works for them, and if we have medical students trained for 21st-century medicine," he said. "It will take a lot of work and a lot of effort and a lot of focus, but at the end, we think there will be a healthier future for our health care system ... physicians, [and] ... our country as a whole."

SAN ANTONIO – The American Medical Association is working toward numerous goals that stand to improve health care and the practice of medicine, including some that target issues of particular concern to psychiatrists, according to Dr. Jeremy A. Lazarus.

In general, the efforts aim to enhance professional satisfaction for physicians, improve outcomes for patients, and transform medical education to make sure that current medical students are prepared to practice 21st century medicine, Dr. Lazarus of the University of Colorado Denver and immediate past president of the AMA at said at the annual meeting of the American College of Psychiatrists.

During an update on the AMA’s efforts, Dr. Lazarus described several recent activities and successes, and reflected on the "tremendous partnership that the AMA has with psychiatry and the (American Psychiatric Association).""We have a long history of fighting together," he said, referring to successes such as the decade-long effort that resulted in getting the mental health parity bill passed, the joining together of more than 80 state and specialty societies to address and combat efforts – like a successful effort in New Mexico in 2002 – to give prescribing privileges to psychologists, and – recently – participation in the Joining Forces initiative to ensure that veterans with posttraumatic stress disorder, post-combat depression, or traumatic brain injury receive the care and resources they need.

Other recent AMA activities and successes outlined by Dr. Lazarus include:

• Testifying to the U.S. Senate regarding the Sunshine Act provisions of the Affordable Care Act.

Dr. Lazarus said he voiced the AMA’s support for transparency, but cautioned that physicians need to have the right to review reported information to ensure accuracy.

The AMA is committed to making sure that "the powers that be in Washington, D.C., hear physicians’ concerns loud and clear," he said.

• Working with state medical societies and associations on numerous legislative issues that affect physicians and health care.

"The AMA achieved many legislative victories in 2012-2013, including truth-in-advertising legislation, preserving existing medical liability reforms, protecting the patient-physician relationship, and also turning back and defeating many scope of practice expansions," he said.

For example, in conjunction with 10 other specialty groups, the AMA helped to overturn a Florida law that prohibited physicians from talking to patients/parents about guns in the home and gun safety, and from making any note about the conversation in patient charts.

"We feel it is imperative that lawmakers not get in the way of physician-patient communication," he said.

• Working toward Medicare reform.

Efforts toward reform have been ongoing for a decade or more, Dr. Lazarus said.

"We are close to the finish line," he noted.

Efforts to repeal the Medicare Sustainable Growth Rate formula and to move toward different systems of paying physicians continue, as scores of state and specialty societies work together to develop a system that will provide many options for payment for physicians that will reward physicians for savings in the health care system, support practice investments so that physicians can move to different forms of practicing, and tie physician payment to their own actions rather than to those of others whom they can’t control.

"We got great news on Feb. 6 – there is now joint legislation to repeal the SGR that’s advancing in both the House and the Senate," he said, noting that the impending legislation is the result of work by the AMA and other organizations working together to "keep this issue alive, to try to modify the bills as they were going through the House and the Senate, and to make sure we got to a positive outcome."

"We want the Medicare payment program to be a stable 21st-century program that can meet the growing health care needs of our senior population, and we’ve been very pleased that the committees have made many changes recommended by the AMA," he said.

The current bill under consideration – the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 – includes a repeal of the SGR formula, automatic positive payment updates of 0.5% for the next 5 years, a consolidated and simpler Medicare quality reporting program, and the ability to transition to different models of care.

"We’ve now got a March 31 deadline. If nothing is done, there will be a 24% cut in Medicare payments, so stay tuned. We’re looking for things to advance ... we haven’t been any closer than we are right now, so we’re very hopeful," he said.

Those interested in participating in the effort to reform Medicare can visit the AMA’s FixMedicareNow.org website for more information, he noted.

The efforts mentioned by Dr. Lazarus are among the matters "high on the list for AMA advocacy," but are just a small part of the AMA’s activities.

"We’re also looking at the big picture in terms of the health care system in this country to try to lead a major effort on the big issues," he said.

Among the concerns are the "tremendously overburdened system," with 50 million individuals uninsured and $2.7 trillion in annual spending (18% of gross domestic product) with outcomes that are poorer than those of other developed countries – and with an estimated increase of spending up to $4.6 trillion (20% of GDP) by 2020. The fragmented delivery system, with a lack of coordination of care and an epidemic of chronic conditions that account for 75% of the spending, also are among the concerns being addressed by the AMA.

Facing these tremendously complicated and difficult situations, the AMA decided to "take our years of training on addressing major issues, and put them to work on what amounts to an AMA policy triathlon," Dr. Lazarus said, referring to the three-pronged plan of enhancing physician satisfaction, improving health outcomes, and accelerating needed changes in medical education.

"We’ve committed to finishing this race," he said, noting that it will be a long one.

Efforts to improve care delivery models include collaboration with the RAND Corp. to conduct field research at 30 diverse practice settings across the country to identify factors associated with success and satisfaction.

Results are forthcoming, but initial findings suggest that what physicians care most about is the ability to deliver high-quality care.

The plan is to create tools to help physicians choose the best model for meeting their particular needs, and to advocate both federally and locally to promote adoption of models that improve physician and patient satisfaction, he said.

The AMA will continue to work to remove regulatory barriers that get in the way of providing quality health care, level the playing field with health insurers, help facilitate relationships with hospital and other payers to ensure a physician leadership role in emerging care models, and explore solutions to improve electronic health record platforms, he added.

As for improving health outcomes, efforts include several initiatives and partnerships designed to reduce disease burden and the cost burden associated with some of the most pervasive and troubling health conditions, such as diabetes. As for medical education, the AMA has issued $1 million in grants to 11 medical schools to advance new ways of teaching – such as through more flexible and individualized learning plans – to better prepare students for practicing in the changing health care environment.

"Just imagine the possibilities if we are even partially successful with this strategic plan – if we have increased quality of care, healthier patients, lower costs, and physicians working in a sustainable health environment that they have created themselves and that they think works for them, and if we have medical students trained for 21st-century medicine," he said. "It will take a lot of work and a lot of effort and a lot of focus, but at the end, we think there will be a healthier future for our health care system ... physicians, [and] ... our country as a whole."

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.

SAN ANTONIO – Brief cognitive-behavioral therapy is particularly helpful for the treatment of insomnia, including insomnia that occurs in association with depression or other psychiatric conditions.

Even cognitive-behavioral therapy (CBT) sessions lasting only 8-10 minutes, when accompanied by informational handouts, can lead to improvements in insomnia, Dr. Donna M. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, said during a premeeting workshop on high-yield brief CBT at the annual meeting of the American College of Psychiatrists.

"It’s really rapid," she said of the intervention and its effects on insomnia.

Dr. Sudak noted that in patients with depression, it often is assumed that "the insomnia component of depression really has to do with the depression itself," but in fact, treating the insomnia appears to also make a real difference in the depression, suggesting the two conditions are interrelated.

"CBT works really well, and it also may be important in terms of managing other conditions," she said.

In an article that synthesized the relevant empirical evidence related to the efficacy of CBT for insomnia (CBT-I) and the benzodiazepines and benzodiazepine-receptor antagonists often used for the treatment of insomnia, Dr. Sudak notes that chronic insomnia affects an estimated 6% to 10% of the population, and that the highly prevalent sleep disorder is accompanied by significant daytime impairment.

"Insomnia has significant consequences for daytime functioning and health-related quality of life. The disorder conveys serious occupational and economic burdens, including mood disturbance, sleepiness, fatigue, cognitive impairment, and high rates of absenteeism and ‘presenteeism,’ " she wrote.

She also noted that insomnia sufferers are at increased risk of compromised psychological and physical health.

In the article, which has been accepted for publication in the International Journal of Cognitive Psychotherapy, she notes that CBT-I, which typically involves six to eight individual or group sessions that employ strategies such as stimulus control, sleep restriction, relaxation, and cognitive restructuring, is recommended by the American Academy of Sleep Medicine and the National Institutes of Health based on the substantial support in the literature for its efficacy and effectiveness in treating primary insomnia. She cites, for example, a meta-analysis of randomized controlled trials that suggests that CBT-I has moderate to large effects with respect to improving sleep (Sleep and Biol. Rhythms 2011;9:24-34).

Other studies have found a high rate of treatment response and clinically significant remissions with CBT-I, she noted.

CBT-I for comorbid insomnia, psychiatric illness

CBT-I also is beneficial in patients with coexisting insomnia and psychiatric illness.

"An estimated 30% to 90% of psychiatric patients have sleep disturbances. Conversely, patients with psychiatric illness account for an estimated 40% to 50% of patients with chronic insomnia.

Furthermore, those with anxiety and depression have a fivefold increase in the likelihood of having chronic insomnia, compared with those without anxiety or depression, and numerous studies suggest that insomnia that coexists with a range of psychiatric and medical conditions benefits from the application of CBT-I.

"It is therefore worthwhile to pursue strategies for combining CBT-I and pharmacotherapy in such groups," she wrote.

However, despite the high comorbidity, insomnia is rarely independently treated with CBT-I in mood disorders, which leaves patients vulnerable to relapse of depression, as well as to morbidity associated with sleep disturbance.

"It is increasingly recognized that insomnia is often best conceptualized as a separate entity that should be managed with specific, targeted treatment rather than secondary to depression treatment," she wrote, noting that since the prevalence of comorbid insomnia increases with the severity of depression, and since insomnia increases the risk of recurrence of depression and suicide, the most important take-home lesson from the literature might well be that when patients have both major depression and insomnia, a treatment targeting both conditions is warranted.

Indeed, data increasingly suggest that CBT-I is such a treatment.

In a recent study presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, 87% of 66 patients with depression whose insomnia resolved after 4 brief biweekly CBT sessions also experienced significant declines in their depression symptoms after 8 weeks of treatment – regardless of whether they were treated with an antidepressant drug or received placebo. The rate of improvement in depression symptoms in those who also experienced improvement in their insomnia was almost twice as high as in patients who did not experience improvement in their insomnia, according to the lead author, Colleen E. Carney, Ph.D., of Ryerson University, Toronto.

CBT-I in older adults

In another recent study, Nicole Lovato, Ph.D., of Flinders University, Adelaide, South Australia, and her colleagues demonstrated that 4 brief weekly CBT group-administered sessions for insomnia were effective for improving symptoms in older adults with sleep maintenance insomnia.

For that randomized controlled trial involving 118 adults with a mean age of 64 years, the investigators compared 86 CBT patients with 32 waitlist controls. At 3-month follow-up, those in the treatment group experienced significant improvements in the timing and quality of sleep, including later bedtime, earlier out-of-bed time, reduced wake after sleep onset, and improved sleep efficiency (Sleep 2014;37:117-26).

Improvements were seen on the Insomnia Severity Index, Flinders Fatigue Scale, Epworth Sleepiness Scale, Daytime Feeling and Functioning Scale, Sleep Anticipatory Anxiety Questionnaire, Dysfunctional Beliefs and Attitudes Scale, and Sleep Self-Efficacy Scale, they reported.

"These changes were supported by large effect sizes (1.14-1.54) and were significantly greater than the wait-list group both immediately following treatment and at 3-month follow-up," the investigators wrote.

The CBT intervention included bedtime restriction therapy, sleep education, and cognitive restructuring.

The group-administered treatment program used in the study, "promises to be a brief and inexpensive answer to the effective treatment of insomnia in the older population," they concluded.

Dr. Sudak’s paper also addressed CBT-I use in the elderly, who have a substantial risk of insomnia and who frequently use hypnotics for treatment of insomnia.

"Treatment with CBT-I is effective in older adults and results are more durable than medication," she said, noting that 50% of elders who receive CBT-I sustain remission for at least 2 years.

CBT-I is also effective in older adults with comorbid medical conditions; among those who are dependent on hypnotics, CBT-I helps improve subjective sleep quality and sleep onset latency. Several randomized controlled trials indicate that CBT-I "may be particularly effective in facilitating hypnotic withdrawal in older adults," she said, noting that this is important given that hypnotics are associated with falls, confusion, and constipation in this population.

She cited a study that demonstrated that the best outcomes are achieved if CBT-I is employed first, then medication added, then medication discontinued prior to the end of CBT-I (Lancet 2012;379:1129-41).

CBT-I and cost savings

Another recent study shows that in addition to improving symptoms, brief CBT-I reduces health care utilization and costs.

The medical records review of 84 outpatients with a mean age of 54 years showed that for 37 patients who completed at least three CBT session for insomnia, and 32 who completed at least three sessions and who experienced significant sleep improvement, all health care use and cost variables, with the exception of number of medications, decreased significantly or trended toward decrease after treatment.

The average decrease in CPT costs was $200 for completers and $210 for responders. No significant decreases occurred in those who did not complete therapy, Christina McCrae, Ph.D., of the University of Florida, Gainesville, and her colleagues reported in February in the Journal of Clinical Sleep Medicine.

Patients included in the study received sleep and sleep hygiene education, stimulus control therapy, sleep restriction, a 10-minute relaxation exercise, and cognitive therapy during up to 6 weekly treatment sessions led by clinical psychology graduate students and predoctoral interns.

Although the study is limited by its small sample size and non-normal data distribution, the findings underscore a need for greater dissemination of brief CBT for insomnia; as few as 3 sessions are needed for significant improvement, the therapy can be delivered by novice clinicians, and the therapy is associated with reduced costs and reduced burden of insomnia, the investigators concluded (J. Clin. Sleep Med. 2014;10:127-35).

While the cost of brief treatment, which was $460 in this study, might negate the short-term savings seen in the first 6 months after therapy, the effects of therapy are durable, so CBT for insomnia has the potential to produce substantial long-term savings, the investigator said in a press statement. They noted that this is particularly true when these results are extrapolated to the large population of insomnia patients in the U.S. health care system.

Dr. Sudak is a coauthor of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Publishing, 2010). She receives book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also is on an editorial board and receives honoraria from Elsevier and is a consultant for Takeda Pharmaceuticals. Dr. Lovato and Dr. McCrae reported having no disclosures.

SAN ANTONIO – Dr. Carolyn B. Robinowitz knows a thing or two about creativity in leadership.

As one of very few female medical students at Washington University School of Medicine in St. Louis in the 1960s (women comprised only 8% of her graduating class), Dr. Robinowitz learned quickly that it would take a creative approach to successfully navigate a career in what was then the male-dominated world of medicine.

She became the first female psychiatrist elected to the American Board of Psychiatry and Neurology and the first female president of that organization, the first woman to serve as president of the Council of Medical Specialty Societies, and the first female psychiatrist to be named dean of a U.S. medical school (at Georgetown University School of Medicine) – just to name a few of her accomplishments. Dr. Robinowitz also holds the mantle as the 134th president of the American Psychiatric Association.

During a session on creativity in leadership at the annual meeting of the American College of Psychiatrists, she shared a bit about her experiences, including a not-so-traditional (at the time) dual medical career marriage, and a rather traditional habit of moving to where there was work – for her husband. She talked about the creative ways she made those moves work in her favor and how she found ways to fit in with her male colleagues – and to make a name for herself in medicine.

After a move to Miami, for example, she had to work hard to gain the respect of her colleagues, and in addition to making sure to demonstrate her medical expertise, she also became an expert on something else of great importance there that helped her to be part of the conversation: the Miami Dolphins.

An important lesson she learned – which is something that is true with patients, as well – is that to work with people, you have to be where they are, she said.

She quickly moved up the career ladder.

Along the way she encountered covert – and sometime overt – gender bias and cultural expectations that conflicted with her goals, she said, adding that women have come a long way since then.

When she first began her work as dean at Georgetown, women comprised 32% of medical students. When she left the position 6 years later, that figure had risen to 47%.

"A lot of that was what was going on nationally," she said.

But she did work to play a part – in her own way – in making a difference.

"Just being visible" was something she found to be important. When young women visited for admissions committee interviews, she would make it a point to be visible, even if just to walk past.

"The person with the applicants would say, ‘Oh, that’s our dean,’ " she explained, noting that she felt her presence provided encouragement to those young women, and reinforced the fact that women could – and did –have a place at the head of the table.

Dr. Robinowitz said that during the times when women were such a small minority in leadership roles, there was a sense that the problem would "fix itself when the pipeline got more full," and that female physicians just needed to act more like male physicians if they wanted to succeed.

Research – and her own personal experience – show that is not the case; women and men sometimes have very different styles of leadership.

For example, men might tend to be results oriented, while women tend to be more concerned with the process.

In the past decade, a great deal of research from the fields of neuroscience, psychology, and business has looked at the behaviors of men and women in the workplace; some of that research shows that many of the attributes of women leaders are more conducive to success, she noted.

One survey of CEOs, for example, showed that women are particularly adept at skills such as team building and participatory decision making – important for working successfully with the "new millennial workforce" – and that women are equally as effective as are men when it comes to efficient communication and intellectual stimulation.

"We also know that there is different communication – that women tend to have ‘rapport’ communication (building relationships), while male communication is more ‘report’ communication. We also know that men are more unilaterally focused, more results focused, and less concerned with how to get there," she said.

Regardless of gender-based differences in leadership style (and there are many exceptions when it comes to these generalities), there are certain individual strategies that all leaders, male or female, should keep in mind to attain success and happiness in the work environment, Dr. Robinowitz said.

First, it is important realize that it’s not all about being number one, Dr. Robinowitz said.

Sometimes there is more fulfillment – more of an ability to make a difference – at a different level.

Her other take-home messages are as follows:

• Don’t underestimate your skills, the transferability of your experience, or how you can benefit from continuing professional development (formal or informal).

• Find a mentor, and be a mentor – and remember mentoring is not about age (a person can mentor someone older), it’s about mutual interest and the ability to communicate effectively.

• Work hard.

• Don’t be afraid to speak up.

• Don’t be afraid to be wrong – that’s where learning occurs.

• Have fun; organizational work (with specialty groups such as the American College of Psychiatrists) is different from clinical work and has important value – and it can be fun and fulfilling.

• Lead; don’t treat. As a psychiatrist in a leadership position, it can be tempting to treat, but your coworkers are not your patients," she said.

• Know the 10% rule – 10% of the people do 90% of the work, but don’t discount the other 90% as they have something to contribute, and should be encouraged to do so.

• Give positive reinforcement.

• Know that money has limitations; people really want to be seen as successful and to be part of a successful mission.

• Understand that a win-win approach involving compromise is valuable.

• Recognize your limits and support fresh ideas, energy, resources, and new leaders.

Most importantly, according to Dr. Robinowitz: Enjoy yourself.

Dr. Robinowitz reported having no disclosures.

cpnews@frontlinemedcom.com

SAN ANTONIO – Dr. Carolyn B. Robinowitz knows a thing or two about creativity in leadership.

As one of very few female medical students at Washington University School of Medicine in St. Louis in the 1960s (women comprised only 8% of her graduating class), Dr. Robinowitz learned quickly that it would take a creative approach to successfully navigate a career in what was then the male-dominated world of medicine.

She became the first female psychiatrist elected to the American Board of Psychiatry and Neurology and the first female president of that organization, the first woman to serve as president of the Council of Medical Specialty Societies, and the first female psychiatrist to be named dean of a U.S. medical school (at Georgetown University School of Medicine) – just to name a few of her accomplishments. Dr. Robinowitz also holds the mantle as the 134th president of the American Psychiatric Association.

During a session on creativity in leadership at the annual meeting of the American College of Psychiatrists, she shared a bit about her experiences, including a not-so-traditional (at the time) dual medical career marriage, and a rather traditional habit of moving to where there was work – for her husband. She talked about the creative ways she made those moves work in her favor and how she found ways to fit in with her male colleagues – and to make a name for herself in medicine.

After a move to Miami, for example, she had to work hard to gain the respect of her colleagues, and in addition to making sure to demonstrate her medical expertise, she also became an expert on something else of great importance there that helped her to be part of the conversation: the Miami Dolphins.

An important lesson she learned – which is something that is true with patients, as well – is that to work with people, you have to be where they are, she said.

She quickly moved up the career ladder.

Along the way she encountered covert – and sometime overt – gender bias and cultural expectations that conflicted with her goals, she said, adding that women have come a long way since then.

When she first began her work as dean at Georgetown, women comprised 32% of medical students. When she left the position 6 years later, that figure had risen to 47%.

"A lot of that was what was going on nationally," she said.

But she did work to play a part – in her own way – in making a difference.

"Just being visible" was something she found to be important. When young women visited for admissions committee interviews, she would make it a point to be visible, even if just to walk past.

"The person with the applicants would say, ‘Oh, that’s our dean,’ " she explained, noting that she felt her presence provided encouragement to those young women, and reinforced the fact that women could – and did –have a place at the head of the table.

Dr. Robinowitz said that during the times when women were such a small minority in leadership roles, there was a sense that the problem would "fix itself when the pipeline got more full," and that female physicians just needed to act more like male physicians if they wanted to succeed.

Research – and her own personal experience – show that is not the case; women and men sometimes have very different styles of leadership.

For example, men might tend to be results oriented, while women tend to be more concerned with the process.

In the past decade, a great deal of research from the fields of neuroscience, psychology, and business has looked at the behaviors of men and women in the workplace; some of that research shows that many of the attributes of women leaders are more conducive to success, she noted.

One survey of CEOs, for example, showed that women are particularly adept at skills such as team building and participatory decision making – important for working successfully with the "new millennial workforce" – and that women are equally as effective as are men when it comes to efficient communication and intellectual stimulation.

"We also know that there is different communication – that women tend to have ‘rapport’ communication (building relationships), while male communication is more ‘report’ communication. We also know that men are more unilaterally focused, more results focused, and less concerned with how to get there," she said.

Regardless of gender-based differences in leadership style (and there are many exceptions when it comes to these generalities), there are certain individual strategies that all leaders, male or female, should keep in mind to attain success and happiness in the work environment, Dr. Robinowitz said.

First, it is important realize that it’s not all about being number one, Dr. Robinowitz said.

Sometimes there is more fulfillment – more of an ability to make a difference – at a different level.

Her other take-home messages are as follows:

• Don’t underestimate your skills, the transferability of your experience, or how you can benefit from continuing professional development (formal or informal).

• Find a mentor, and be a mentor – and remember mentoring is not about age (a person can mentor someone older), it’s about mutual interest and the ability to communicate effectively.

• Work hard.

• Don’t be afraid to speak up.

• Don’t be afraid to be wrong – that’s where learning occurs.

• Have fun; organizational work (with specialty groups such as the American College of Psychiatrists) is different from clinical work and has important value – and it can be fun and fulfilling.

• Lead; don’t treat. As a psychiatrist in a leadership position, it can be tempting to treat, but your coworkers are not your patients," she said.

• Know the 10% rule – 10% of the people do 90% of the work, but don’t discount the other 90% as they have something to contribute, and should be encouraged to do so.

• Give positive reinforcement.

• Know that money has limitations; people really want to be seen as successful and to be part of a successful mission.

• Understand that a win-win approach involving compromise is valuable.

• Recognize your limits and support fresh ideas, energy, resources, and new leaders.

Most importantly, according to Dr. Robinowitz: Enjoy yourself.

Dr. Robinowitz reported having no disclosures.

cpnews@frontlinemedcom.com

SAN ANTONIO – Dr. Carolyn B. Robinowitz knows a thing or two about creativity in leadership.

As one of very few female medical students at Washington University School of Medicine in St. Louis in the 1960s (women comprised only 8% of her graduating class), Dr. Robinowitz learned quickly that it would take a creative approach to successfully navigate a career in what was then the male-dominated world of medicine.

She became the first female psychiatrist elected to the American Board of Psychiatry and Neurology and the first female president of that organization, the first woman to serve as president of the Council of Medical Specialty Societies, and the first female psychiatrist to be named dean of a U.S. medical school (at Georgetown University School of Medicine) – just to name a few of her accomplishments. Dr. Robinowitz also holds the mantle as the 134th president of the American Psychiatric Association.

During a session on creativity in leadership at the annual meeting of the American College of Psychiatrists, she shared a bit about her experiences, including a not-so-traditional (at the time) dual medical career marriage, and a rather traditional habit of moving to where there was work – for her husband. She talked about the creative ways she made those moves work in her favor and how she found ways to fit in with her male colleagues – and to make a name for herself in medicine.

After a move to Miami, for example, she had to work hard to gain the respect of her colleagues, and in addition to making sure to demonstrate her medical expertise, she also became an expert on something else of great importance there that helped her to be part of the conversation: the Miami Dolphins.

An important lesson she learned – which is something that is true with patients, as well – is that to work with people, you have to be where they are, she said.

She quickly moved up the career ladder.

Along the way she encountered covert – and sometime overt – gender bias and cultural expectations that conflicted with her goals, she said, adding that women have come a long way since then.

When she first began her work as dean at Georgetown, women comprised 32% of medical students. When she left the position 6 years later, that figure had risen to 47%.

"A lot of that was what was going on nationally," she said.

But she did work to play a part – in her own way – in making a difference.

"Just being visible" was something she found to be important. When young women visited for admissions committee interviews, she would make it a point to be visible, even if just to walk past.

"The person with the applicants would say, ‘Oh, that’s our dean,’ " she explained, noting that she felt her presence provided encouragement to those young women, and reinforced the fact that women could – and did –have a place at the head of the table.

Dr. Robinowitz said that during the times when women were such a small minority in leadership roles, there was a sense that the problem would "fix itself when the pipeline got more full," and that female physicians just needed to act more like male physicians if they wanted to succeed.

Research – and her own personal experience – show that is not the case; women and men sometimes have very different styles of leadership.

For example, men might tend to be results oriented, while women tend to be more concerned with the process.

In the past decade, a great deal of research from the fields of neuroscience, psychology, and business has looked at the behaviors of men and women in the workplace; some of that research shows that many of the attributes of women leaders are more conducive to success, she noted.

One survey of CEOs, for example, showed that women are particularly adept at skills such as team building and participatory decision making – important for working successfully with the "new millennial workforce" – and that women are equally as effective as are men when it comes to efficient communication and intellectual stimulation.

"We also know that there is different communication – that women tend to have ‘rapport’ communication (building relationships), while male communication is more ‘report’ communication. We also know that men are more unilaterally focused, more results focused, and less concerned with how to get there," she said.

Regardless of gender-based differences in leadership style (and there are many exceptions when it comes to these generalities), there are certain individual strategies that all leaders, male or female, should keep in mind to attain success and happiness in the work environment, Dr. Robinowitz said.

First, it is important realize that it’s not all about being number one, Dr. Robinowitz said.

Sometimes there is more fulfillment – more of an ability to make a difference – at a different level.

Her other take-home messages are as follows:

• Don’t underestimate your skills, the transferability of your experience, or how you can benefit from continuing professional development (formal or informal).

• Find a mentor, and be a mentor – and remember mentoring is not about age (a person can mentor someone older), it’s about mutual interest and the ability to communicate effectively.

• Work hard.

• Don’t be afraid to speak up.

• Don’t be afraid to be wrong – that’s where learning occurs.

• Have fun; organizational work (with specialty groups such as the American College of Psychiatrists) is different from clinical work and has important value – and it can be fun and fulfilling.

• Lead; don’t treat. As a psychiatrist in a leadership position, it can be tempting to treat, but your coworkers are not your patients," she said.

• Know the 10% rule – 10% of the people do 90% of the work, but don’t discount the other 90% as they have something to contribute, and should be encouraged to do so.

• Give positive reinforcement.

• Know that money has limitations; people really want to be seen as successful and to be part of a successful mission.

• Understand that a win-win approach involving compromise is valuable.

• Recognize your limits and support fresh ideas, energy, resources, and new leaders.

Most importantly, according to Dr. Robinowitz: Enjoy yourself.

Dr. Robinowitz reported having no disclosures.

cpnews@frontlinemedcom.com

SAN ANTONIO – Questions about how health care reform will affect the practice of medicine are nothing new, but there is particular uncertainty for the field of psychiatry, according to the president-elect of the American Psychiatric Association.

One reason for the uncertainty is that payment streams for psychiatric and substance use care are distinctive and poorly understood, and the scope of the relative sectors – including public, commercial, state, and self-pay – are unique in the field of psychiatry, Dr. Paul Summergrad explained at the annual meeting of the American College of Psychiatrists.

According to a 2011 article in the New England Journal of Medicine, the greatest percentages of U.S. medical spending overall were from "private insurance" and "Medicare, out-of-pocket, and other private spending" (37% and 35%, respectively), but for mental health, Medicaid spending exceeded both of these (28% vs. 27% and 22%, respectively), and "other state and local spending" was also higher (18% vs. 6% for medicine overall).

For substance abuse, other state and local spending dominated at 36%, followed by Medicaid spending at 21% (N. Engl. J. Med. 2011;365:973-5).

"If you look at the total dollars that come into our world, they look different from the outset than they do for anyone else in medicine," Dr. Summergrad said, noting that patients with substance abuse, for example, fall mainly outside of the commercial insurance system.

Also, within Medicaid – the largest payer, the percentage spent on mental health services is about three times higher than for commercial insurance.

The impact of the Affordable Care Act through mandated parity rules for coverage of mental health and substance abuse services could provide for tremendous expansion of services within the insurance realm, he said.

Another reason for the uncertainty is a lack of understanding about the substantial extent and effects of medical and psychiatric comorbidities on the total cost of medical care, and the fact that most ambulatory psychiatric care is provided by physicians other than psychiatrists, said Dr. Summergrad, Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts Medical Center in Boston.

"This is both a challenge and an opportunity; it’s an opportunity to really improve the care of the patients, and not just individuals who have severe psychiatric illness," he said, noting that those improvements could come not only in terms of the quality of care, but in terms of the cost effectiveness of care – a factor that could benefit both patients and the care system, including psychiatrists.

"The care of our patients is deeply embedded in the general health care system, so for us, the payer environment is problematic, and we know that payment differentials have been deeply discriminatory. It’s part of the reason why, along with intrusive utilization review, many psychiatrists don’t take insurance," he said.

The impact of fourth-party carve-out models on both payment and models of care have had a very problematic impact on both the public and commercial sector – in particular because they don’t take into account the extent of medical-psychiatric comorbidity, he added, noting that "the impact of this commoditization really depends in large measure on stigma associated with mental health and substance abuse care."

Many patients in need can’t get adequate care, and the stigma associated with mental illness keeps them from addressing the problems with insurers or benefits managers.

"The insurance industry has relied, in my view, on that stigma to allow [psychiatric] care to be marginalized," he said.

However, studies consistently show that patients with mental illness and substance abuse issues have higher rates of medical comorbidities, and that patients with chronic medical conditions have higher rates of mental health issues. These interactions result in poorer outcomes and higher costs.

In many studies, the costs associated with treating patients with a psychiatric and/or substance use disorder are two to three times greater when accounting for a patient’s total medical costs, compared with the costs for patients without a behavioral condition, Dr. Summergrad said.

One way that health care reform can benefit patients and potentially psychiatry is through medical and psychiatric care integration. One collaborative team approach involves a behavioral health or chronic disease care manager in a primary care office working with a consulting psychiatrist. In a multisite randomized trial (the Improving Mood: Promoting Access to Collaborative Treatment, or IMPACT study) involving more than 1,800 patients, this collaborative care approach was associated with a 50% or greater reduction in depressive symptoms in 45% of intervention patients, compared with only 19% of usual care patients (Am. J. Manag. Care 2008;14:95-100).

The approach also was associated with decreased costs over a period of 4 years.

Barriers to adoption of such integrated care models include a shrinking proportion of psychiatrists compared with the growing mental health workforce; financing (the disconnected medical and psychiatric payment systems for psychiatrists and other specialists); the fact that electronic medical records systems are not well established in psychiatry, which raises operational and confidentiality issues; and the discrimination against psychiatric care in many insurance plans.

"We need to have systems that are much more granular, but the reality is that the data that drive payment systems, and the data that are going to be associated with quality metrics for both individual physicians and systems as a whole, will come out of these systems. If we remain on the outside of them, it will marginalize and put the patients we care for at serious risk," Dr. Summergrad said.

Overcoming the barriers will require research regarding medically comorbid illness and models of care. In addition, increased training and education for all physicians, including those currently in practice and those in training, and electronic medical records that are well adapted for psychiatric practice are needed, he said.

Dr. Summergrad reported having done nonpromotional speaking for CME Outfitters.

cpnews@frontlinemedcom.com

SAN ANTONIO – Questions about how health care reform will affect the practice of medicine are nothing new, but there is particular uncertainty for the field of psychiatry, according to the president-elect of the American Psychiatric Association.

One reason for the uncertainty is that payment streams for psychiatric and substance use care are distinctive and poorly understood, and the scope of the relative sectors – including public, commercial, state, and self-pay – are unique in the field of psychiatry, Dr. Paul Summergrad explained at the annual meeting of the American College of Psychiatrists.

According to a 2011 article in the New England Journal of Medicine, the greatest percentages of U.S. medical spending overall were from "private insurance" and "Medicare, out-of-pocket, and other private spending" (37% and 35%, respectively), but for mental health, Medicaid spending exceeded both of these (28% vs. 27% and 22%, respectively), and "other state and local spending" was also higher (18% vs. 6% for medicine overall).

For substance abuse, other state and local spending dominated at 36%, followed by Medicaid spending at 21% (N. Engl. J. Med. 2011;365:973-5).

"If you look at the total dollars that come into our world, they look different from the outset than they do for anyone else in medicine," Dr. Summergrad said, noting that patients with substance abuse, for example, fall mainly outside of the commercial insurance system.

Also, within Medicaid – the largest payer, the percentage spent on mental health services is about three times higher than for commercial insurance.

The impact of the Affordable Care Act through mandated parity rules for coverage of mental health and substance abuse services could provide for tremendous expansion of services within the insurance realm, he said.

Another reason for the uncertainty is a lack of understanding about the substantial extent and effects of medical and psychiatric comorbidities on the total cost of medical care, and the fact that most ambulatory psychiatric care is provided by physicians other than psychiatrists, said Dr. Summergrad, Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts Medical Center in Boston.

"This is both a challenge and an opportunity; it’s an opportunity to really improve the care of the patients, and not just individuals who have severe psychiatric illness," he said, noting that those improvements could come not only in terms of the quality of care, but in terms of the cost effectiveness of care – a factor that could benefit both patients and the care system, including psychiatrists.

"The care of our patients is deeply embedded in the general health care system, so for us, the payer environment is problematic, and we know that payment differentials have been deeply discriminatory. It’s part of the reason why, along with intrusive utilization review, many psychiatrists don’t take insurance," he said.

The impact of fourth-party carve-out models on both payment and models of care have had a very problematic impact on both the public and commercial sector – in particular because they don’t take into account the extent of medical-psychiatric comorbidity, he added, noting that "the impact of this commoditization really depends in large measure on stigma associated with mental health and substance abuse care."

Many patients in need can’t get adequate care, and the stigma associated with mental illness keeps them from addressing the problems with insurers or benefits managers.

"The insurance industry has relied, in my view, on that stigma to allow [psychiatric] care to be marginalized," he said.

However, studies consistently show that patients with mental illness and substance abuse issues have higher rates of medical comorbidities, and that patients with chronic medical conditions have higher rates of mental health issues. These interactions result in poorer outcomes and higher costs.

In many studies, the costs associated with treating patients with a psychiatric and/or substance use disorder are two to three times greater when accounting for a patient’s total medical costs, compared with the costs for patients without a behavioral condition, Dr. Summergrad said.

One way that health care reform can benefit patients and potentially psychiatry is through medical and psychiatric care integration. One collaborative team approach involves a behavioral health or chronic disease care manager in a primary care office working with a consulting psychiatrist. In a multisite randomized trial (the Improving Mood: Promoting Access to Collaborative Treatment, or IMPACT study) involving more than 1,800 patients, this collaborative care approach was associated with a 50% or greater reduction in depressive symptoms in 45% of intervention patients, compared with only 19% of usual care patients (Am. J. Manag. Care 2008;14:95-100).

The approach also was associated with decreased costs over a period of 4 years.

Barriers to adoption of such integrated care models include a shrinking proportion of psychiatrists compared with the growing mental health workforce; financing (the disconnected medical and psychiatric payment systems for psychiatrists and other specialists); the fact that electronic medical records systems are not well established in psychiatry, which raises operational and confidentiality issues; and the discrimination against psychiatric care in many insurance plans.

"We need to have systems that are much more granular, but the reality is that the data that drive payment systems, and the data that are going to be associated with quality metrics for both individual physicians and systems as a whole, will come out of these systems. If we remain on the outside of them, it will marginalize and put the patients we care for at serious risk," Dr. Summergrad said.

Overcoming the barriers will require research regarding medically comorbid illness and models of care. In addition, increased training and education for all physicians, including those currently in practice and those in training, and electronic medical records that are well adapted for psychiatric practice are needed, he said.

Dr. Summergrad reported having done nonpromotional speaking for CME Outfitters.

cpnews@frontlinemedcom.com

SAN ANTONIO – Questions about how health care reform will affect the practice of medicine are nothing new, but there is particular uncertainty for the field of psychiatry, according to the president-elect of the American Psychiatric Association.

One reason for the uncertainty is that payment streams for psychiatric and substance use care are distinctive and poorly understood, and the scope of the relative sectors – including public, commercial, state, and self-pay – are unique in the field of psychiatry, Dr. Paul Summergrad explained at the annual meeting of the American College of Psychiatrists.

According to a 2011 article in the New England Journal of Medicine, the greatest percentages of U.S. medical spending overall were from "private insurance" and "Medicare, out-of-pocket, and other private spending" (37% and 35%, respectively), but for mental health, Medicaid spending exceeded both of these (28% vs. 27% and 22%, respectively), and "other state and local spending" was also higher (18% vs. 6% for medicine overall).

For substance abuse, other state and local spending dominated at 36%, followed by Medicaid spending at 21% (N. Engl. J. Med. 2011;365:973-5).

"If you look at the total dollars that come into our world, they look different from the outset than they do for anyone else in medicine," Dr. Summergrad said, noting that patients with substance abuse, for example, fall mainly outside of the commercial insurance system.

Also, within Medicaid – the largest payer, the percentage spent on mental health services is about three times higher than for commercial insurance.

The impact of the Affordable Care Act through mandated parity rules for coverage of mental health and substance abuse services could provide for tremendous expansion of services within the insurance realm, he said.

Another reason for the uncertainty is a lack of understanding about the substantial extent and effects of medical and psychiatric comorbidities on the total cost of medical care, and the fact that most ambulatory psychiatric care is provided by physicians other than psychiatrists, said Dr. Summergrad, Dr. Frances S. Arkin Professor and chairman of psychiatry at Tufts Medical Center in Boston.

"This is both a challenge and an opportunity; it’s an opportunity to really improve the care of the patients, and not just individuals who have severe psychiatric illness," he said, noting that those improvements could come not only in terms of the quality of care, but in terms of the cost effectiveness of care – a factor that could benefit both patients and the care system, including psychiatrists.

"The care of our patients is deeply embedded in the general health care system, so for us, the payer environment is problematic, and we know that payment differentials have been deeply discriminatory. It’s part of the reason why, along with intrusive utilization review, many psychiatrists don’t take insurance," he said.

The impact of fourth-party carve-out models on both payment and models of care have had a very problematic impact on both the public and commercial sector – in particular because they don’t take into account the extent of medical-psychiatric comorbidity, he added, noting that "the impact of this commoditization really depends in large measure on stigma associated with mental health and substance abuse care."

Many patients in need can’t get adequate care, and the stigma associated with mental illness keeps them from addressing the problems with insurers or benefits managers.

"The insurance industry has relied, in my view, on that stigma to allow [psychiatric] care to be marginalized," he said.

However, studies consistently show that patients with mental illness and substance abuse issues have higher rates of medical comorbidities, and that patients with chronic medical conditions have higher rates of mental health issues. These interactions result in poorer outcomes and higher costs.

In many studies, the costs associated with treating patients with a psychiatric and/or substance use disorder are two to three times greater when accounting for a patient’s total medical costs, compared with the costs for patients without a behavioral condition, Dr. Summergrad said.

One way that health care reform can benefit patients and potentially psychiatry is through medical and psychiatric care integration. One collaborative team approach involves a behavioral health or chronic disease care manager in a primary care office working with a consulting psychiatrist. In a multisite randomized trial (the Improving Mood: Promoting Access to Collaborative Treatment, or IMPACT study) involving more than 1,800 patients, this collaborative care approach was associated with a 50% or greater reduction in depressive symptoms in 45% of intervention patients, compared with only 19% of usual care patients (Am. J. Manag. Care 2008;14:95-100).

The approach also was associated with decreased costs over a period of 4 years.

Barriers to adoption of such integrated care models include a shrinking proportion of psychiatrists compared with the growing mental health workforce; financing (the disconnected medical and psychiatric payment systems for psychiatrists and other specialists); the fact that electronic medical records systems are not well established in psychiatry, which raises operational and confidentiality issues; and the discrimination against psychiatric care in many insurance plans.

"We need to have systems that are much more granular, but the reality is that the data that drive payment systems, and the data that are going to be associated with quality metrics for both individual physicians and systems as a whole, will come out of these systems. If we remain on the outside of them, it will marginalize and put the patients we care for at serious risk," Dr. Summergrad said.

Overcoming the barriers will require research regarding medically comorbid illness and models of care. In addition, increased training and education for all physicians, including those currently in practice and those in training, and electronic medical records that are well adapted for psychiatric practice are needed, he said.

Dr. Summergrad reported having done nonpromotional speaking for CME Outfitters.

cpnews@frontlinemedcom.com

SAN ANTONIO – Your patients are likely "Googling" you; is turnabout fair play?

The question is a popular one these days. A quick Internet search reveals numerous articles, editorials, and blog posts on the topic. Some authors focus on potential positive aspects of the practice, while others decry it as unethical.

Attendees at an interactive session on "Professionalism and Psychiatry in the Online and Digital Age" held during the annual meeting of the American College of Psychiatrists were similarly divided. One admitted to Googling a patient to verify whether stories the patient told were true or were evidence of grandiosity. Others said they could see value in learning information about a patient that they might not otherwise know.

Another knew of a program where routine Googling of patients was expected.

Some said it’s best to avoid the temptation altogether – that obtaining information online about a patient can be harmful to the therapeutic relationship.

Most agreed there are important ethical implications to consider.

It will take some time before the ethical – and legal – implications of Googling and other online and digital activities are defined and standards established, but one of the session leaders, Dr. Sandra M. DeJong of Cambridge (Mass.) Health Alliance recommended an article from Harvard Review of Psychiatry as an excellent resource for decision-making about Googling patients.

In the article, entitled "Patient-Targeted Googling: The Ethics of Searching Online for Patient Information," Dr. Brian K. Clinton of McLean Hospital, Belmont, Mass., and his colleagues acknowledge that "the Internet has changed the way that medicine and psychiatry are practiced, as patients and physicians now routinely search online for medical and personal information," and they believe that patient-targeted "Googling" – a term they consider to be synonymous with "Internet searching" – is "widespread and deserving of professional and ethical consideration."

While the practice occurs among all types of physicians, it is "especially complicated in a relationship between a patient and a psychiatrist (or other mental health clinician)," they wrote, explaining that what they referred to as patient-targeted Googling, or PTG, has the potential to enhance or interfere with processes inherent in therapeutic relationship (Harv. Rev. Psychiatry 2010;18:103-12).

In some cases, a search can garner useful information. An example involves a case in which collateral information obtained aided in the safety assessment of a suicidal patient in an emergency room. Conversely, ethically problematic motivations for PTG might include curiosity, voyeurism, and habit – and these motivations can result in behaviors that would be considered boundary violations in another setting (for example, Googling a patient’s address and viewing a photograph of her home, which might be analogous to driving by her house).

"Before searching online for patients, psychiatrists should consider the intention of the search, its potential value or risk to the patient, and the anticipated effect of gaining previously unknown information. The psychiatrist is obligated to act in a way that will respect the patient’s best interests and that adheres to professional ethics. However, the results and the potential danger of PTG are not always intuitive or consciously available prior to searches," they wrote.

To aid in the decision making, they propose a pragmatic model for "considering PTG that focuses on practical results of searches and that aims to minimize the risk of exploiting patients."

The model, which provides an approach to clinical ethics that specifies core values that should be balanced in patient care – specifically, the psychiatrist should focus ethical deliberations on the results of the decision both for the patient in question and on general moral principles.

"The psychiatrist must consider how PTG would affect the treatment relationship and the progress toward treatment goals – a thought process that may involve discussions with the patient, the patient’s family, and a clinician’s community of supervisors, colleagues, and consultants," they said.

The model urges clinicians to – at the very least – consider the following six questions on a case-by-case basis before searching online for a patient:

• Why do I want to conduct this search?

• Would my search advance or compromise the treatment?

• Should I obtain informed consent from the patient prior to searching?

• Should I share the results of the search with the patient?

• Should I document the findings of the search in the medical record?

• How do I monitor my motivations and the ongoing risk-benefit profile of searching?

If the answers to these questions suggest that patient-targeted Googling would not serve a particular patient’s best interest or that PTG would not promote the therapeutic process, the psychiatrist should not go forward with the search, the authors said.

Dr. DeJong reported having no disclosures. Dr. Clinton and his colleagues also reported having no disclosures.

SAN ANTONIO – Your patients are likely "Googling" you; is turnabout fair play?

The question is a popular one these days. A quick Internet search reveals numerous articles, editorials, and blog posts on the topic. Some authors focus on potential positive aspects of the practice, while others decry it as unethical.

Attendees at an interactive session on "Professionalism and Psychiatry in the Online and Digital Age" held during the annual meeting of the American College of Psychiatrists were similarly divided. One admitted to Googling a patient to verify whether stories the patient told were true or were evidence of grandiosity. Others said they could see value in learning information about a patient that they might not otherwise know.

Another knew of a program where routine Googling of patients was expected.

Some said it’s best to avoid the temptation altogether – that obtaining information online about a patient can be harmful to the therapeutic relationship.

Most agreed there are important ethical implications to consider.

It will take some time before the ethical – and legal – implications of Googling and other online and digital activities are defined and standards established, but one of the session leaders, Dr. Sandra M. DeJong of Cambridge (Mass.) Health Alliance recommended an article from Harvard Review of Psychiatry as an excellent resource for decision-making about Googling patients.

In the article, entitled "Patient-Targeted Googling: The Ethics of Searching Online for Patient Information," Dr. Brian K. Clinton of McLean Hospital, Belmont, Mass., and his colleagues acknowledge that "the Internet has changed the way that medicine and psychiatry are practiced, as patients and physicians now routinely search online for medical and personal information," and they believe that patient-targeted "Googling" – a term they consider to be synonymous with "Internet searching" – is "widespread and deserving of professional and ethical consideration."

While the practice occurs among all types of physicians, it is "especially complicated in a relationship between a patient and a psychiatrist (or other mental health clinician)," they wrote, explaining that what they referred to as patient-targeted Googling, or PTG, has the potential to enhance or interfere with processes inherent in therapeutic relationship (Harv. Rev. Psychiatry 2010;18:103-12).

In some cases, a search can garner useful information. An example involves a case in which collateral information obtained aided in the safety assessment of a suicidal patient in an emergency room. Conversely, ethically problematic motivations for PTG might include curiosity, voyeurism, and habit – and these motivations can result in behaviors that would be considered boundary violations in another setting (for example, Googling a patient’s address and viewing a photograph of her home, which might be analogous to driving by her house).

"Before searching online for patients, psychiatrists should consider the intention of the search, its potential value or risk to the patient, and the anticipated effect of gaining previously unknown information. The psychiatrist is obligated to act in a way that will respect the patient’s best interests and that adheres to professional ethics. However, the results and the potential danger of PTG are not always intuitive or consciously available prior to searches," they wrote.

To aid in the decision making, they propose a pragmatic model for "considering PTG that focuses on practical results of searches and that aims to minimize the risk of exploiting patients."

The model, which provides an approach to clinical ethics that specifies core values that should be balanced in patient care – specifically, the psychiatrist should focus ethical deliberations on the results of the decision both for the patient in question and on general moral principles.

"The psychiatrist must consider how PTG would affect the treatment relationship and the progress toward treatment goals – a thought process that may involve discussions with the patient, the patient’s family, and a clinician’s community of supervisors, colleagues, and consultants," they said.

The model urges clinicians to – at the very least – consider the following six questions on a case-by-case basis before searching online for a patient:

• Why do I want to conduct this search?

• Would my search advance or compromise the treatment?

• Should I obtain informed consent from the patient prior to searching?

• Should I share the results of the search with the patient?

• Should I document the findings of the search in the medical record?

• How do I monitor my motivations and the ongoing risk-benefit profile of searching?

If the answers to these questions suggest that patient-targeted Googling would not serve a particular patient’s best interest or that PTG would not promote the therapeutic process, the psychiatrist should not go forward with the search, the authors said.

Dr. DeJong reported having no disclosures. Dr. Clinton and his colleagues also reported having no disclosures.

SAN ANTONIO – Your patients are likely "Googling" you; is turnabout fair play?

The question is a popular one these days. A quick Internet search reveals numerous articles, editorials, and blog posts on the topic. Some authors focus on potential positive aspects of the practice, while others decry it as unethical.

Attendees at an interactive session on "Professionalism and Psychiatry in the Online and Digital Age" held during the annual meeting of the American College of Psychiatrists were similarly divided. One admitted to Googling a patient to verify whether stories the patient told were true or were evidence of grandiosity. Others said they could see value in learning information about a patient that they might not otherwise know.

Another knew of a program where routine Googling of patients was expected.

Some said it’s best to avoid the temptation altogether – that obtaining information online about a patient can be harmful to the therapeutic relationship.

Most agreed there are important ethical implications to consider.

It will take some time before the ethical – and legal – implications of Googling and other online and digital activities are defined and standards established, but one of the session leaders, Dr. Sandra M. DeJong of Cambridge (Mass.) Health Alliance recommended an article from Harvard Review of Psychiatry as an excellent resource for decision-making about Googling patients.

In the article, entitled "Patient-Targeted Googling: The Ethics of Searching Online for Patient Information," Dr. Brian K. Clinton of McLean Hospital, Belmont, Mass., and his colleagues acknowledge that "the Internet has changed the way that medicine and psychiatry are practiced, as patients and physicians now routinely search online for medical and personal information," and they believe that patient-targeted "Googling" – a term they consider to be synonymous with "Internet searching" – is "widespread and deserving of professional and ethical consideration."

While the practice occurs among all types of physicians, it is "especially complicated in a relationship between a patient and a psychiatrist (or other mental health clinician)," they wrote, explaining that what they referred to as patient-targeted Googling, or PTG, has the potential to enhance or interfere with processes inherent in therapeutic relationship (Harv. Rev. Psychiatry 2010;18:103-12).

In some cases, a search can garner useful information. An example involves a case in which collateral information obtained aided in the safety assessment of a suicidal patient in an emergency room. Conversely, ethically problematic motivations for PTG might include curiosity, voyeurism, and habit – and these motivations can result in behaviors that would be considered boundary violations in another setting (for example, Googling a patient’s address and viewing a photograph of her home, which might be analogous to driving by her house).

"Before searching online for patients, psychiatrists should consider the intention of the search, its potential value or risk to the patient, and the anticipated effect of gaining previously unknown information. The psychiatrist is obligated to act in a way that will respect the patient’s best interests and that adheres to professional ethics. However, the results and the potential danger of PTG are not always intuitive or consciously available prior to searches," they wrote.

To aid in the decision making, they propose a pragmatic model for "considering PTG that focuses on practical results of searches and that aims to minimize the risk of exploiting patients."

The model, which provides an approach to clinical ethics that specifies core values that should be balanced in patient care – specifically, the psychiatrist should focus ethical deliberations on the results of the decision both for the patient in question and on general moral principles.

"The psychiatrist must consider how PTG would affect the treatment relationship and the progress toward treatment goals – a thought process that may involve discussions with the patient, the patient’s family, and a clinician’s community of supervisors, colleagues, and consultants," they said.

The model urges clinicians to – at the very least – consider the following six questions on a case-by-case basis before searching online for a patient:

• Why do I want to conduct this search?

• Would my search advance or compromise the treatment?

• Should I obtain informed consent from the patient prior to searching?

• Should I share the results of the search with the patient?

• Should I document the findings of the search in the medical record?

• How do I monitor my motivations and the ongoing risk-benefit profile of searching?

If the answers to these questions suggest that patient-targeted Googling would not serve a particular patient’s best interest or that PTG would not promote the therapeutic process, the psychiatrist should not go forward with the search, the authors said.

Dr. DeJong reported having no disclosures. Dr. Clinton and his colleagues also reported having no disclosures.

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Treatment adherence is a problem for about half of all psychiatric patients, but certain high-yield techniques for enhancing adherence can be used effectively during brief cognitive-behavioral therapy sessions, according to Dr. Donna M. Sudak and Dr. Jesse H. Wright.

Maximizing the collaborative therapeutic relationship is particularly important, as this can facilitate open discussion about adherence, Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.), said in a joint presentation at the annual meeting of the American College of Psychiatrists.

"No electronic reminder is as helpful for adherence as having a good relationship with the patient and asking regularly [about adherence]," Dr. Sudak said.

It is important, however, to ask in a way that helps patients tell you about any difficulties they are having.

Asking a patient, "You’re taking your medicine every day, right?" will typically elicit an affirmative response, in part because people just want to be good patients, Dr. Sudak said.

Encouraging open dialogue about how hard it can be to remember to take medication every day, and explaining to patients that the goal is to have them take their medication as often as possible – and discussing ways to reach that goal – will likely do more to encourage patients to discuss adherence problems, she said.

In addition to normalizing the illness and adherence problems through such dialogue, providing patients with printed educational materials about the importance of adherence – and repeating these efforts at intervals to reinforce the message – is also important, Dr. Sudak said, noting that this is particularly important for patients who have just been discharged from the hospital, because these patients might have particular difficulty remembering instructions.

Asking first about the benefits of medication, rather than about side effects, also is an important strategy; this puts the focus on the positive aspects of treatment, instead of reminding the patient about the potential negative aspects, she said.

And remember that adherence issues change across the life cycle. For example, when a patient transitions from home to a college dorm or to independent living, adherence issues can arise. Thus, adherence should be routinely monitored.

Collaboration, a nonjudgmental approach, and realistic expectations are important throughout treatment.

Other strategies for promoting adherence include involving the patient’s family if possible and if helpful; linking adherence to the patient’s goals and most distressing symptoms; and simplifying medication regimens when possible.

Jointly and relentlessly pursuing solutions to side effects also is imperative; pointing out that medication has effects that are desired, as well as effects that are not – and working to minimize the undesirable effects – will encourage persistence on the part of the patient, Dr. Sudak said.

She and Dr. Wright provided numerous specific behavioral and cognitive methods for improving adherence.

Behavioral methods that might help patients with adherence include storing medication in a place where it will be seen each day, pairing medication taking with routine activities, and using a reminder system, such as a 7-day pill container.

"These are very commonsense kinds of approaches ... but they can really be very helpful," Dr. Wright said.

Behavioral contracts and written adherence plans also can prove helpful, he said, adding that it also is important to analyze barriers to adherence and to devise written methods for overcoming those barriers.

An example of a barrier might be running out of samples of medication before a scheduled doctor visit; a potential solution would be to have the patient count pills carefully, call the nurse a week before more samples will be needed, and make a plan to pick them up during a weekday while the nurse is available.

Another barrier might be a voice telling a patient that the medication is causing harm; a possible solution would be to remind the patient that the voices are a symptom of the patient’s illness, and that it is not necessary to do what the voices say. The patient also could be instructed to review a list of positive reasons to take the medication.

These and other behavioral techniques and barriers/solutions can be written on 3-by-5 "coping cards" that capture the key points of the session. The patient can take these cards home to serve as reminders.

As for cognitive methods, Dr. Sudak and Dr. Wright recommended eliciting cognitions about taking medication, and about the illness, to identify and modify dysfunctional family beliefs about medication, and to write down the old belief and the new more-functional belief.

Cognitions that can interfere with adherence include:

• Specific ideas about the illness or medication – such as a belief that antidepressant medications are addictive. Education should be provided to counter these beliefs.

• More general beliefs (family or cultural beliefs/values) about physicians or medication – such as beliefs that individuals should be able to handle medical problems on their own. These beliefs should be examined, and logical analysis should be employed to explore and correct them.

• Beliefs about medication that echo beliefs about the self. For example, a patient might believe he is vulnerable in general, and thus believe he is prone to side effects. Belief work can help in these cases.

• Basic mistrust and interpersonal beliefs that interfere more globally. More specific trust work can help in these cases.

Additional cognitive strategies that can help with adherence are pro/con lists, evaluating thoughts for accuracy, developing new rules and beliefs about medication, problem solving and planning, and cognitive rehearsal, they said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

As for pacing, Dr. Sudak advised thinking of CBT as a learning model; if too much material is given too quickly it won’t be absorbed.

Session notes help focus time

The use of therapy notes can help with maintaining the focus on session goals. Providing and requesting feedback also can help keep the session on target, and can provide a summary with take-home points.

Handouts and homework assignments are important for brief CBT sessions, and should be readily available; in the brief session setting, there is little time for searching and downloading. Keep handouts and/or an Internet resource list readily accessible. It might be helpful to have a library of handouts or self-help materials set up in your office, Dr. Sudak noted.

Homework assignments such as thought records and activity schedules can be useful but should be developed collaboratively and rehearsed in advance to allow for troubleshooting when obstacles arise. Always be sure to follow up on assignments from the last session, Dr. Sudak said.

Difficulties with homework completion occur and should be normalized. When such difficulties occur, the assignments should be evaluated to determine whether they were appropriate and relevant to the session or problem, and it should be determined whether the patient was adequately prepared. Starting or completing assignments during the session can help, and it is important to check for negative thoughts about the homework, and to identify barriers and find solutions, she said.

"When the homework doesn’t go so well, part of what we have to do is not give up on it. One of the things that happens a lot, I think ... is that it’s easier to jettison that plan than to figure out why it didn’t work," Dr. Sudak said.

Figuring out what the barriers are can be a learning experience for both patient and therapist.

Brief CBT sessions have a great deal of potential for helping many patients, but in Dr. Sudak’s and Dr. Wright’s experiences, brief CBT sessions should be avoided in:

• Those with a diagnosis and complexity that suggest a need for full-course, standard CBT. They might include patients with personality disorders, history of trauma, family conflict, resistant depression, or acute crisis.

• Patients in whom brief CBT sessions have been tried but did not appear to meet their needs.

Dr. Sudak and Dr. Wright are two of four coauthors of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Association, 2010). They receive book royalties from American Psychiatric Publishing; Lippincott Williams & Wilkins; and John Wiley & Sons. Dr. Sudak is also on the editorial board of, and receives honoraria from, Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

As for pacing, Dr. Sudak advised thinking of CBT as a learning model; if too much material is given too quickly it won’t be absorbed.

Session notes help focus time

The use of therapy notes can help with maintaining the focus on session goals. Providing and requesting feedback also can help keep the session on target, and can provide a summary with take-home points.

Handouts and homework assignments are important for brief CBT sessions, and should be readily available; in the brief session setting, there is little time for searching and downloading. Keep handouts and/or an Internet resource list readily accessible. It might be helpful to have a library of handouts or self-help materials set up in your office, Dr. Sudak noted.

Homework assignments such as thought records and activity schedules can be useful but should be developed collaboratively and rehearsed in advance to allow for troubleshooting when obstacles arise. Always be sure to follow up on assignments from the last session, Dr. Sudak said.

Difficulties with homework completion occur and should be normalized. When such difficulties occur, the assignments should be evaluated to determine whether they were appropriate and relevant to the session or problem, and it should be determined whether the patient was adequately prepared. Starting or completing assignments during the session can help, and it is important to check for negative thoughts about the homework, and to identify barriers and find solutions, she said.

"When the homework doesn’t go so well, part of what we have to do is not give up on it. One of the things that happens a lot, I think ... is that it’s easier to jettison that plan than to figure out why it didn’t work," Dr. Sudak said.

Figuring out what the barriers are can be a learning experience for both patient and therapist.

Brief CBT sessions have a great deal of potential for helping many patients, but in Dr. Sudak’s and Dr. Wright’s experiences, brief CBT sessions should be avoided in:

• Those with a diagnosis and complexity that suggest a need for full-course, standard CBT. They might include patients with personality disorders, history of trauma, family conflict, resistant depression, or acute crisis.

• Patients in whom brief CBT sessions have been tried but did not appear to meet their needs.

Dr. Sudak and Dr. Wright are two of four coauthors of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Association, 2010). They receive book royalties from American Psychiatric Publishing; Lippincott Williams & Wilkins; and John Wiley & Sons. Dr. Sudak is also on the editorial board of, and receives honoraria from, Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Cognitive-behavioral therapy, or CBT, can be effectively used during brief sessions in certain cases.

For example, brief CBT sessions can be useful in patients with Axis I disorders for which pharmacotherapy is being used effectively, and in patients in whom symptom complexity does not appear to require longer sessions, Dr. Donna M. Sudak and Dr. Jesse H. Wright said during a premeeting workshop at the annual meeting of the American College of Psychiatrists.

Other patients for whom brief CBT sessions might be indicated include inpatients; those with a preference for shorter sessions; those on long-term pharmacotherapy; and those with illnesses for which brief treatment may be advantageous, including psychosis, bipolar disorder, obsessive-compulsive disorder, uncomplicated anxiety disorders, and substance abuse requiring frequent visits, according to Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia, and Dr. Wright, professor and director of the Depression Center at the University of Louisville (Ky.).

The format for providing brief CBT sessions can vary. For some patients, an initial evaluation followed by brief sessions might be appropriate. Other patients might be best served with several 50-minute sessions, followed by a transition to brief sessions later in treatment. Some patients might require a mixture of 50-minute and brief sessions, and some might do well with a team approach in which a psychiatrist provides brief sessions and a nonphysician CBT-trained therapist provides longer sessions or a nonphysician therapist provides therapy from a different orientation.

The selected format should be based on the patient’s need and preference, and can change over time, Dr. Wright said, noting that many patients prefer brief sessions because of time constraints.

Numerous high-yield interventions can be used in brief CBT sessions. Some examples include adherence enhancement; behavioral activation, which is particularly potent for treating depression; breathing retraining; CBT for insomnia, which is an area of increasing interest; cognitive-behavioral rehearsal; collaborative empiricism; collaborative goal setting; computer-assisted CBT; eliciting of and modification of automatic thoughts; exposure; cognitive error identification; motivational interviewing; psychoeducation; and relapse prevention.

Dr. Sudak and Dr. Wright shared several strategies aimed at enhancing the effect of brief CBT sessions.

Improving each session

First, make certain to have a clear formulation of the patient, they said.

Key elements of the formulation include diagnosis and symptoms; formative influences; situational issues and biological factors; strengths and assets; cross-sectional and longitudinal formulation; and a working hypothesis and treatment plan that is developed based on how all of these factors "pull together to influence the way this person thinks about the world, and [her] skill set in terms of working with other people and managing [her] own emotions."

Miniformulations developed during the course of care also can be helpful. These formulations address a specific issue that needs to be addressed "right now." Such formulations are collaboratively developed, simple and easily understood, and provide targeted direction for therapy interventions.

Dr. Sudak said she will sometimes draw a miniformulation on a whiteboard during a session, and will have the patient draw the same on a piece of paper to take home. She gave an example involving a "feedback loop" in a patient who hears teenage girls laughing while he is walking to the store. He experiences the thought that they are laughing at him, and that they therefore must think he is "a loser." This causes feelings of fear and sadness, leading him to keep his eyes down and return home without going to the store.

The miniformulation in this case involved drawing a circular graphic to outline the feedback loop and work on strategies for developing more realistic, healthier thoughts about being out in public, and for working on becoming more comfortable around other people, gradually increasing the ability to be in public settings.

A specific treatment plan should be developed for each session based on these formulations.

Techniques used in the course of treatment should include those that are most likely to be effective in briefer formats. Particularly high-yield techniques for brief CBT sessions include adherence enhancement, behavioral activation, and thought change records.

Also, special attention should be paid to the relationship and to pacing.

Enhancing the therapeutic relationship is important regardless of session length, but is particularly important for brief sessions, Dr. Wright said.

Helpful techniques for relationship building include emphasizing a team approach with shared responsibility; staying tuned to the patient’s emotion – and responding with accurate empathy; giving the patient your full attention and avoiding digressions; choosing targets for change with high relevance and opportunities for success; and building communication skills. In addition, listening carefully, giving clear explanations, summarizing key points, and asking for and giving feedback help build relationships.

As for pacing, Dr. Sudak advised thinking of CBT as a learning model; if too much material is given too quickly it won’t be absorbed.

Session notes help focus time

The use of therapy notes can help with maintaining the focus on session goals. Providing and requesting feedback also can help keep the session on target, and can provide a summary with take-home points.

Handouts and homework assignments are important for brief CBT sessions, and should be readily available; in the brief session setting, there is little time for searching and downloading. Keep handouts and/or an Internet resource list readily accessible. It might be helpful to have a library of handouts or self-help materials set up in your office, Dr. Sudak noted.

Homework assignments such as thought records and activity schedules can be useful but should be developed collaboratively and rehearsed in advance to allow for troubleshooting when obstacles arise. Always be sure to follow up on assignments from the last session, Dr. Sudak said.

Difficulties with homework completion occur and should be normalized. When such difficulties occur, the assignments should be evaluated to determine whether they were appropriate and relevant to the session or problem, and it should be determined whether the patient was adequately prepared. Starting or completing assignments during the session can help, and it is important to check for negative thoughts about the homework, and to identify barriers and find solutions, she said.

"When the homework doesn’t go so well, part of what we have to do is not give up on it. One of the things that happens a lot, I think ... is that it’s easier to jettison that plan than to figure out why it didn’t work," Dr. Sudak said.

Figuring out what the barriers are can be a learning experience for both patient and therapist.

Brief CBT sessions have a great deal of potential for helping many patients, but in Dr. Sudak’s and Dr. Wright’s experiences, brief CBT sessions should be avoided in:

• Those with a diagnosis and complexity that suggest a need for full-course, standard CBT. They might include patients with personality disorders, history of trauma, family conflict, resistant depression, or acute crisis.

• Patients in whom brief CBT sessions have been tried but did not appear to meet their needs.

Dr. Sudak and Dr. Wright are two of four coauthors of the book "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide" (Washington: American Psychiatric Association, 2010). They receive book royalties from American Psychiatric Publishing; Lippincott Williams & Wilkins; and John Wiley & Sons. Dr. Sudak is also on the editorial board of, and receives honoraria from, Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).

SAN ANTONIO – Don’t underestimate the value of a symptom summary worksheet when it comes to working with patients with bipolar disorder, Dr. Jesse H. Wright advised.

The symptom summary worksheet is a powerful tool for helping a patient learn to recognize the signs of an impending shift toward hypomania or depression, Dr. Wright said at the annual meeting of the American College of Psychiatrists.

The purpose of the worksheet is to help the patient and/or family members develop a customized list of early signs that such a shift is occurring, said Dr. Wright, professor and director of the depression center at the University of Louisville (Ky.).

The idea is to help the patient become more attuned to those signs, and to develop cognitive-behavioral or medication strategies that might interrupt the escalation into full-blown mania or very deep depression, he said during a workshop on cognitive-behavioral therapy for brief sessions.

Brief-session CBT can be useful in patients with bipolar disorder, and a review of the symptom summary worksheet can be incorporated into the session, he said.

"We want them to develop a skill set so that when they start to see something happening, they have something to do for it," he added.

Dr. Donna M. Sudak, who conducted the CBT workshop along with Dr. Wright, cautioned that symptom summary worksheets won’t necessarily have an immediate impact.

"It may not work the first time, but over time, as people really begin to develop the capacity to look at the onset of symptoms and catch it earlier, it’s really pretty remarkable. ... I call it an ‘early warning system,’ " said Dr. Sudak, professor and director of the psychotherapy training program at Drexel University, Philadelphia.

A simple example provided by Dr. Wright involved a patient who starts going to bed an hour later than usual and who spends that time surfing the Web, which gets her "worked up about new business ideas." This leads to sleep disruption, and she begins to escalate.

Monitoring this behavior allows for a plan to be put into place to address sleep hygiene issues when they arise.

"If she’s willing to do that, it might interrupt full-blown mania," Dr. Wright said.

Dr. Sudak and Dr. Wright are two of four coauthors of the book, "High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide (Washington: American Psychiatric Publishing, 2010). They both receive book royalties from American Psychiatric Publishing; Lippincott, Williams & Wilkins; and John Wiley & Sons. Dr. Sudak also serves on an editorial board, receives honoraria from Elsevier, and is a consultant for Takeda Pharmaceuticals. Dr. Wright also receives royalties for the development of software (Empower Interactive, Mindstreet).