Antidepressants and Suicide in Young People
New Ways to Treat Depression
Telemedicine in ArizonaRevised 8/30/06 by Heather Hopkins
A growing number of psychiatrists and other doctors are practicing telemedicine---treating patients through television links. This can be an important source of services for patients in remote or not easily accessible areas that may be underserved by psychiatrists or other medical specialists. Medicaid programs in about 18 states now pay for some telemedicine care and at least 8 states specifically include psychiatry.1 Private insurers are required to reimburse patients for telepsychiatry in 6 states.
Telemedicine started with NASA, as a means to take care of the health needs of astronauts. As the technology got better, it moved into commercial use and improved care in other areas, such as prisons, where safety issues for doctors are a concern and reimbursement for care is relatively easy. The expansion of these programs to include patients in rural areas of the country, which often have social problems like poverty and drug abuse, is occurring as the cost of technology decreases. For psychiatric care, all that is needed is that both the patient and the doctor have a television-mounted camera, angled so they can maintain the illusion of looking into each other’s eyes in real time. For other kinds of medicine, more equipment is required.
Arizona leads the country in both the number and variety of national awards received by its telemedicine programs.2 The University of Arizona–based Arizona Telemedicine Program (ATP) provides a wide variety of telehealth services, including telepsychiatry, and education to patients and physicians at more than 140 sites throughout the state. It has been recognized as the premier telemedicine program in the nation and has won seven national awards as a top program, as a major provider of distance education over a telemedicine network, and for telehealth research. The Northern Arizona Regional Behavioral Health Authority (NARBHA) provides telebehavioral health service through mental health centers and has received three awards as a top program.
Training in telemedicine will be a central part of the curriculum at the University of Arizona’s College of Medicine campus in Phoenix, which will open in July 2007.3 The Phoenix program is part of the Tucson college’s accredited programs, but it will not duplicate the Tucson campus. The curriculum at the Tucson campus is being revised to include new themes of public health, gender-specific medicine, equity issues, preventive medicine, and special populations. In Phoenix, the focus will be on other components: personalized medicine, biomedical informatics, scholarly work, a team-based approach to medicine, and ways to treat patients at a distance. Administrators want to increase early clinical experience. One way to do this is through telemedicine, because medical students would be able to see patients earlier in their training, without actually treating them.
In May 2006, Dr. Ronald S. Weinstein, ATP director, was invited to participate in a meeting at the White House for the Federal Interagency Medical Directors.2 He presented information on two innovative projects being developed in Arizona: eHealthU and UltraClinicsTM. eHealthU is an Internet portal that will provide a number of different health-related training programs and telehealth services. It is part of the new Institute for Advanced Medicine and Telehealth (THealth), which will be headquartered on the College of Medicine’s Phoenix campus. Through eHealthU, state agencies will be able to work together on various programs in disease prevention, public education, correctional telemedicine, children’s health care, and home-health nursing. It will increase access to teaching and training for people in remote areas. UltraClinicsTM uses “virtual” group practices to provide more efficient clinic visits and reduce costs. This concept is being tested at the University Physicians Healthcare Hospital at Kino Campus in Tucson. Preliminary data from the UltraClinicsTM project demonstrates the flexibility of the process to decrease the time it takes for a patient to receive a diagnosis and enter into care.
Mental health services are now widely available throughout Arizona using telemedicine. Dr. Sara Gibson, who is based in Flagstaff, has been treating patients through telepsychiatry for 10 years.1 She treats patients in Apache County, which has 69,000 residents, widespread problems of poverty, drug use, child abuse, and high suicide rates, but no local psychiatrists. According to her, seeing a doctor over the television may actually be better for some psychiatric patients than seeing one in person. Some individuals are overwhelmed with distracting sensory data when they are in the physical presence of another human being. In particular, patients who have a history of trauma or abuse may benefit from the imposed distance and find talking to a doctor this way to be less intimidating.
Dr. Gibson was initially concerned that some patients might incorporate the teleconferencing technology into delusions or come to believe that telemedicine could be used to read thoughts or control people. This has not been a problem with any of her patients. One thing she has learned over the years, though, is to periodically pan the camera around her office when she’s talking with patients with paranoia, so they can see that no one else is in the room. Also, she doesn’t wear stripes or zigzag patterns, as these can look strange on television and be disturbing, especially to an emotionally distraught person.
A telepsychiatric evaluation with Dr. Gibson costs $120, follow-up visits are $40, and the medicines she prescribes may cost thousands of dollars a year. Most of her patients have these costs covered by state programs for low-income and mentally ill people. According to Dr. Ana Maria Lopez, ATP medical director, all health care providers in Arizona, including ACCESS, cover teleconsultations at Medicare rates.
Prisons are a major beneficiary of telemedicine services. Over 80% of specialty medical consultations in Arizona prisons currently take place with a specialist located off-site. Before 1997, prisoners who needed to be treated by specialists were transported in vans or buses, which required tight security to protect public safety, and escapes were a constant concern. For over 20 years, St. Mary’s Hospital in Tucson has been an important service provider for the Department of Corrections. Now, St. Mary’s physicians can care for patients by telemedicine without regard to distance. They use technology like electronic stethoscopes to listen to heart sounds and high-resolution otoscopes to look at eardrums. The University Medical Center in Tucson and Maricopa Medical Center in Phoenix have additional providers on call. Since these telemedicine services began, prisoner grievances concerning their health care have decreased. Some prisoners prefer to receive their health care services by telemedicine, because when they’re sick, they don’t want to be transported somewhere else.
In addition to providing an increased variety of services and more convenience to patients in outlying areas, telemedicine also saves money. Not having to transport prisoners, in addition to increasing public safety, has also saved the state of Arizona over a million dollars.2 Expensive medical air transports of people in rural areas, travel time of psychiatrists, and travel costs for continuing education of professionals have all been greatly reduced.
REFERENCES 1. Johnson K: TV screen, not couch, is required for this session. NY Times, June 8, 2006. 2. Telemedicine updates. Arizona Telemedicine Website, available at http://www.telemedicine.arizona.edu/. Accessed June 28, 2006. 3. Everett-Haynes LM: UA’s doctors of the future: Phoenix med campus focuses on telemedicine. Tucson Citizen June 26, 2006.
Bonds Pass to Build Psychiatric Care Facilities in Pima Countyby Heather Hopkins
On May 16, voters in Pima County approved issuing $54 million in bonds to build an acute care psychiatric hospital and a stand-alone outpatient psychiatric urgent care facility.1 Both facilities are to be constructed on the University Physicians Healthcare Hospital Campus at Kino (UPHK). This money will be added to $12 million in bonds that were approved by voters in May 2004 for partial replacement of existing psychiatric facilities.2
Over 30,000 people are currently receiving some kind of publicly-funded mental health service in Pima County, most of whom have been diagnosed with a mental health disorder. Probably an equal number of individuals in the community with mental illnesses have not been diagnosed and are not receiving treatment. About one-quarter of inmates in the Pima County jail require mental health or substance abuse treatment. Many individuals with behavioral health problems use methamphetamine, and crimes associated with the use of this drug in Pima County are reaching crisis levels.
These kinds of issues impact hospital emergency rooms and law enforcement personnel throughout southern Arizona, in addition to mental health service providers. Many people who need mental health services end up in emergency rooms, jails, or juvenile detention facilities, because there is no where else to take them. Overcrowding in hospitals and emergency rooms disrupts treatment for all patients and threatens patient safety.
The construction of new facilities enabled by the passage of the bond proposals will help with these problems. The psychiatric urgent care center, which will be located near the UPHK campus, will fill a gap in the mental health service delivery system in southern Arizona by reducing the number of mental health and/or substance abuse patients currently being seen in local emergency rooms. It will coordinate services with all hospitals in Pima County, not just with UPHK. But because it will be next to the UPH facility, medical services will be available in case a patient needs an intensive medical evaluation or stabilization of a medical emergency. The urgent care center will not only provide a place for law enforcement officials and other first responders to take many individuals in crisis, it will also help streamline the process of getting them treated.
The other proposal was to spend $36 million on constructing an 80- to 100-bed psychiatric inpatient facility and expanding the psychiatric emergency department on the Kino Campus. The inpatient facility will be built next to the existing hospital and close to the proposed psychiatric urgent care center. Most of the current space for psychiatric inpatients at UPHK is inefficient from an operations and safety standpoint. The Kino Campus has 64 psychiatric inpatient beds divided between two facilities. There is a freestanding 36-bed unit on the northwest side of the hospital, and 28 beds are on the fifth floor of the hospital, in what was originally a medical-surgical unit. None of this space was designed for the care of severely and acutely mentally ill patients, and it cannot be remodeled to address the complex safety, security and quality of care concerns associated with this population. For example, there are areas where adequate visual supervision of patients is not possible from even a few feet away because of obstructed views. There is limited space for day room activities, group therapy, individual evaluations and counseling, medication management, and visitor activities. There is no secure way to take patients outside from the fifth floor unit, and there is a risk of harm to patients who may try to escape from the unit.
In addition to limitations of the current inpatient facilities, the emergency room is too small to handle both patients with behavioral health problems and patients with medical problems safely and efficiently. The proposed expanded emergency department will have space specifically designed for psychiatric patients and will improve security, operational efficiency and treatment opportunities. On average, 12 patients in behavioral health crisis per day are brought to the emergency room of the UPH hospital by law enforcement officials, other community agencies, or family members. They require an average of 8 hours of highly supervised emergency medical care, and may need up to 24 hours of detoxification services, which would be performed in the emergency department if there was a high risk of medical complications. At the same time, the emergency department cares for many other patients with acute medical conditions, and it is a busy, noisy, stressful environment. It is not a good atmosphere for agitated patients nor a safe environment for those who come in contact with them.
In 2004, UPH and the Pima County government entered into a 25-year contract for UPH to take over operations of the county-owned hospital on the Kino Healthcare Campus. This contract served as a foundation to reestablish comprehensive medical services for residents of southern Pima County and to expand healthcare-professional training programs in conjunction with the University of Arizona and other educational institutions. It was also designed to create new jobs and improve economic opportunities in the area. In the past two years, much progress has been made. The number of credentialed physicians at the hospital has increased, surgical cases have grown from 3 to 130 per month, and equipment has been upgraded throughout the hospital. Ambulatory care services have expanded to include a comprehensive neurophysiology laboratory and an innovative clinic in the rapid diagnosis of breast cancer.
Part of the arrangement between UPH and the County is that UPH has to provide inpatient psychiatric services for individuals entering the mandatory evaluation process associated with the Title 36 State Statutes. These are people considered to be in personal crisis. They may present a risk to community safety, and they are often severely and acutely mentally ill. Right now, the Pima County Superior Court conducts legal proceedings associated with the Title 36 process in the hospital. Patient rooms on the fourth floor medical unit are used to house staff and attorneys representing the County Attorney’s office. The court and associated offices are located on the third floor, in one of the hospital’s public areas. This situation presents several problems. Individuals involved in the courtroom procedures could introduce infectious diseases into an environment in which there are medically compromised patients, and there is inadequate security for the protection of patients, hospital visitors, and employees. To expand medical services, the County Attorney’s staff must be moved to another area. The proposed new facilities will help alleviate the space issues involved with these operations.
According to Alan J. Gelenberg, M.D., Professor and Head of Psychiatry at the University of Arizona, the bond money will contribute to the Kino Campus becoming the southern campus of the University of Arizona’s Health Sciences Center. Right now, there is money only for construction, but the county voters being willing to pass something like this, he said, is an important first step. “Then we might find other people to donate money to build on it,” he said. “A philanthropist might endow a new wing or research facilities. Government entities could create programs or new structures. The University also has plans to build a biotechnology park in the same area, a couple of blocks north of Kino. The hope is that the whole area will grow, the economy will improve, the wage scale in our region will rise, and Tucson and southern Arizona will become a biotechnology hub, attracting top scientists from around the world.” He added that both Tucson and Phoenix are putting money into clean industry and programs that will improve the health and well being of the citizens of Arizona. This is another---and large---step in that direction.
REFERENCES
1. Kornman S: Kino bonds passing easily. Tucson Citizen May 16, 2006. 2. Psychiatric care facilities. May 16, 2006 Report on Special Bond Election. Pima County Government Website. Available at http://www.pima.gov/bondelection2006/. Accessed June 26, 2006.
The Role of Genomics and Neuroscience in Psychiatryby Heather Hopkins
Over the past two decades, revolutionary advances have occurred in two areas of science basic to psychiatry---genomics and neuroscience. Despite this, methods of diagnosis and treatment for patients with mental disorders have remained comparatively unchanged during this same time period. In fact, the public health burden of mental illness has increased.
In a commentary in the Journal of the American Medical Association, Drs. Thomas Insel and Remi Quirion contend that mental disorders should be understood and treated as brain disorders.1 They argue that the discipline of psychiatry needs to change and that psychiatrists need to be trained differently. The key, they conclude, is to incorporate genomics and neuroscience into psychiatry without losing our sophisticated understanding of behavior and emotion.
Mental disorders are considered to be genetically complex, not the result of a single causative mutation. Several common genetic variations likely contribute to the risk of an illness like depression or schizophrenia, but their function may center on key intracellular pathways. Now that the human genome has been mapped, we have a guide to individual variation. This tool can be used to identify the genes that make a person vulnerable for genetically complex disorders. But defining the risk of a psychiatric disorder will require three additional steps: identifying the phenotypes of the illnesses (that is, the observable properties produced by the interaction of genes with the environment), gaining access to DNA from enough patients and their relatives, and discovering how to distinguish the important gene-environment interactions.
Genetic vulnerability is not the only risk factor for the development of mental disorders---the environment, in both a social and a physical sense, also plays a role. During most of the last century, psychiatry has examined the roots of adult psychopathology in childhood experiences. Now, we are also looking at molecular mechanisms and how environmental factors during critical periods of development might exert an influence on gene expression. This is similar to studying how environmental toxins might contribute to the later development of cancerous cells. But in the case of mental disorders, the trigger might be a psychosocial experience, and the effects could be limited to a small number of cells in the brain.
It may seem more difficult to measure exposure to a traumatic human experience than to measure exposure to a carcinogen, but a more complicated problem is how to calculate the range of individual responses. We don’t know why a stressful situation may cause depression in one individual but build character in another. Genetic variations may not only confer vulnerability or resilience to risk, they might also alter behaviors that increase or decrease exposure to risk factors. Whether or not exposure to a psychosocial trauma is something that can be quantified is one of the questions that the next generation of clinical neuroscience researchers must address.
The Human Genome Project discovered about 23,000 human genes---about half of which are expressed in the brain. The number of proteins in the brain probably is greater than 100,000, as most genes code for multiple proteins. This discovery phase of neuroscience, often called neurogenomics, will likely change our understanding of neuroanatomy, but may not produce a biomarker for any mental disorder. Other approaches, such as proteomics and metabolomics, may be able to detect unique patterns associated with major mental illnesses by measuring all the available proteins or metabolic pathways. This would allow a finer degree of diagnosis than currently available through clinical observation, but application today is limited by the difficulty of sampling cells in the brain.
Although few genetic variations and proteins have been linked to specific mental disorders, results from molecular and cellular neuroscience studies have increased our understanding of neural regulation and have led to a new hypothesis about the development of depression and how to treat it. Reduced hippocampal volume has been observed in clinical imaging studies of individuals with major depressive disorder. Animal studies have shown that stress reduces the growth of nerve cells (neurogenesis) in these regions. Some antidepressant medications increase the rate of neurogenesis in the hippocampus. The resulting theory is that chronic stress decreases the rate of neurogenesis in a critical area in the brain, bringing about a depressive episode in genetically vulnerable people. This provides molecular mechanisms as new targets for the development of novel classes of drug and behavioral therapies. Biomarkers for mental disorders may also be found through neuroimaging studies, such as functional magnetic resonance imaging (fMRI) or single-photon emission computed tomography (SPECT). It is possible that diagnoses may be made based on patterns of brain activation in particular regions following stimulation. For example, some positron emission tomographic (PET) studies of responders versus nonresponders to selective serotonin reuptake inhibitor (SSRI) antidepressants, as well as studies of SSRI treatment compared with cognitive behavior therapy, have indicated that recovery from depression is associated with decreased activity in an area of the brain called the ventral, medial prefrontal cortex (Area 25). Genetic studies have shown that people with reduced expression of the serotonin transporter are at a higher risk for developing depression following stressful life events. This genetic condition is associated with reduced gray matter volume in Area 25, which links genetic vulnerability and environmental stress to a specific neural circuit that might possibly be used to predict response to treatment.
Drs. Insel and Quirion postulate that psychiatrists of the future will need to be trained as clinical neuroscientists, but that an understanding of interpersonal relationships and the need for nonbiological therapies will still be as necessary in the treatment of patients with mental illness as it is today. Psychosocial therapy following or in conjunction with medication treatment for a mental disorder is similar to physical therapy following surgery for a serious injury, or rehabilitation after recovery from any major medical illness. Psychiatry has long been viewed as separate from the rest of medicine, which contributes to the stigma of mental illness as well as to inadequate care. Viewing psychiatry as a clinical neuroscience will help put it in its proper place alongside other medical specialties.
Current medication treatments for mental disorders focus on symptoms rather than core pathology. A better understanding of the causes of major mental disorders, gained through genomics and neuroscience, will lead to diagnoses based on biomarkers and treatments targeted to pathophysiology rather than symptoms, which should be more effective and eventually more accessible. We stand on the threshold of a revolution. In the foreseeable future, psychiatric diagnoses should be totally reconstructed. Planning for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders already is underway. And the biologically distinct abnormalities identified by neuroscience should help destigmatize these brain disorders and make treatments more effective and safer.
REFERENCES 1. Insel TR, Quirion R: Psychiatry as a clinical neuroscience discipline. JAMA 2005;294:2221–2224.
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