Medscape

07 14 15

Kaiser Health News

Moving Mental Health Policy Out of 'the Dark Ages'

An Interview With Patrick Kennedy

Alana Pockros

July 10, 2015

Former Rep. Patrick Kennedy, D-R.I., was a senior in high school the first time he checked into rehab. His struggle with drug addiction and bipolar disorder continued to haunt him through his 16 years in Congress. But his first-hand experience with these illnesses also drives his long-standing interest in shaping public policies to confront the challenges faced by people with mental health problems.

One of Kennedy’s greatest legislative achievements is spearheading the passage — with the help of his father, the late Sen. Edward Kennedy, D-Mass. — of the landmark Mental Health Parity and Addiction Equity Act of 2008.

Since choosing to leave Capitol Hill in 2010, he has pushed to bring mental health policy out of what he says is “the dark ages” — using the advantages, he says, of coming “from a famous family with a powerful, nationally recognized name. [It] gives me a convening power.”

These days, he is most visible in his role as founder of The Kennedy Forum, an advocacy coalition for the mentally ill and mental health policy, and co-founder of the nonprofit research organization called One Mind.

“One Mind’s mission,” he says, “is to accelerate [mental health] cures and therapy by ensuring that we don’t duplicate science.” To this end, he adds, “we have already … created the largest platform to study traumatic brain injury and PTSD in the world,” bringing other countries into the effort.

Testifying last month before the House Energy and Commerce Subcommittee on Health, he said the pending Helping Families in Mental Health Crisis Act of 2015 would provide resources and programs for psychiatric care. “The time is now” for reform, he said, questioning why “with mental illness and addiction we wait for crisis” instead of intervening early.

KHN reporter Alana Pockros talked with Kennedy about problems he sees in the nation’s mental health system and the steps needed to fix them. The following interview has been edited and condensed.

1. You’ve said that the health system is “stuck in the same mentality as five decades ago.” What does this mean?
2. Culturally, we still assign issues of mental health and addiction [to] moral character. We still assign blame to people with these diseases even though they have been known to be diseases for five decades. … Instead of saying “it’s your fault” to addicts, “you made this choice to start,” we now know to look at this as a biological disease.

So, we need to approach illnesses in a different way. Our science tells us one thing, but our culture has told us some completely different story. That’s why our public policy is medieval. In another 20 years from now, they are going to look back on this period like we look back on segregation [or] bigotry against gays and lesbians.

1. This legislation encompasses a range of mental health issues. What do you think is the top priority?
2. I would say if we want to make a difference on a population basis, the number one issue is prevention. We know upon the first incident of psychosis how to interrupt the cycle of that illness with aggressive treatment, just as if we were to use aggressive treatment for cancer. If we did that, we would dramatically reduce incidence of disability in this country.

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This KHN story can be republished for free (details).

Today we are reacting to an epidemic of untreated mental illness. So the way to deal with that is to build a chronic care or intensive care system so that people are treated and cared for, and not abandoned. That goes back to the first point: we know these are chronic illnesses, yet we don’t employ a chronic care approach to their treatment. Treat it like asthma, treat it like diabetes; treat it in a chronic care management way.

1. In terms of policy change and advocacy, are you targeting the federal level or state governments? How?
2. On the federal level, we are looking at The 21st Century Cures Act. [This bill is designed to speed the drug discovery and approval process. It includes provisions to improve communication and collaboration among researchers.]

It is littered with loopholes on data sharing. [The bill has] so many exceptions to [its] mandate that [scientists] share data, that it really undermines the whole purpose of making [research on mental illness] an urgent task. Even though the biggest [research] funders are taxpayers, through the National Institutes of Health, academia totally sequester and “secret away” all their data and don’t share with anyone else. [Universities] husband that data and try to sell it for profits, even though taxpayers pay for the data. That data belongs to the public, it doesn’t belong to universities. So we won’t learn whether there is an algorithm, because someone is holding back valuable information that could help to provide “the missing piece to the puzzle.” That’s what we are dealing with.

1. How does your new role help you push for change? How has it affected your message?
2. I have been blessed by having led The Mental Health Parity and Addiction Equity Act fight. What that allowed me to have, even though I’m no longer in Congress, is a platform to organize and spur collaboration among the very disparate and fragmented stakeholders in neuroscience and for the clinical delivery of neuroscience. I’ve worked in both of those worlds and enjoyed a position of trust. … I still have some credibility in this space, and I’ve used it.

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Medscape

07 14 15

Kaiser Health News

Doctors Order Fewer Preventive Services for Medicaid Patients

Michelle Andrews

July 10, 2015

Gynecologists ordered fewer preventive services for women who were insured by Medicaid than for those with private coverage, a recent study found.

The study by researchers at the Urban Institute examined how office-based primary care practices provided five recommended preventive services over a five-year period. The services were clinical breast exams, pelvic exams, mammograms, Pap tests and depression screening.

The study used data from the National Ambulatory Medical Care Survey, a federal health database of services provided by physicians in office-based settings. It looked at 12,444 visits to primary care practitioners by privately insured women and 1,519 visits by women who were covered by Medicaid between 2006 and 2010. That difference reflects the fact that the share of women who are privately insured is seven times larger than those on Medicaid, the researchers said. Pregnancy-related visits and visits to clinics were excluded from the analysis.

Overall, 26 percent of the visits by women with Medicaid included at least one of the five services, compared with 31 percent of the visits by privately insured women.

As for specific preventive services, the study found "strong evidence" that visits by Medicaid patients were less likely include a clinical breast exam or a Pap test, says Stacey McMorrow, a senior research associate at the Urban Institute's Health Policy Center and the study's lead author. The differences for depression screening weren't statistically significant, and once patient characteristics such as age, race and home address were taken into account weren't significant for mammograms or pelvic exams either.

For example, 20.5 percent of visits by privately insured women included a clinical breast exam, and 16.5 percent of visits included a Pap test. But the percentage of Medicaid-insured visits that included those services was only 12 percent and 9.5 percent, respectively. (The differences narrowed but remained statistically significant when adjusted for patient characteristics.)

The Medicaid-insured women were not necessarily receiving lower quality care, according to the study. They may have been receiving additional care at a community health clinic or from a nurse practitioner, for example, but the study only examined physician services provided in office-based practices.

In addition, privately insured women may have been receiving services more frequently than recommended. For example, current guidelines generally recommend a Pap test to screen for cervical cancer every three years. But if a patient asks for a Pap test every year the doctor may provide it, McMorrow says.

In addition, private insurers generally pay providers better than does Medicaid, sometimes significantly better, she says: "Where providers are getting reimbursed better, they're going to provide services more frequently."

Medscape Medical News

Pediatrics. Published online July 13, 2015.

Only Half of Abused Children Evaluated for Occult Fracture

Jenni Laidman

July 13, 2015

Despite some 20 years of recommendations to perform a skeletal survey on infants and toddlers with injuries associated with abuse, hospital personnel failed to conduct such surveys in roughly half of suspected abuse cases, according to results from a study published online July 13 in Pediatrics.

Joanne N. Wood, MD, MSHP, from the Children’s Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and colleagues examined data from 4486 children younger than 2 years with a diagnosis of abuse or injuries often associated with abuse at 366 hospitals from 2009 to 2013.

The study indicated that 48% of children with an abuse diagnosis and 51% of infants with traumatic brain injury were evaluated with a skeletal survey for occult fracture. Only 53% of infants with femur fractures were examined for further fractures, the researchers found.

Previous studies suggest that skeletal surveys would have revealed occult fractures in approximately 25% to 30% of the children in the study, which means about 1 in every 7 or 8 children might have had an undiagnosed occult fracture, the authors report.

However, Kristine A. Campbell, MD, associate professor, Department of Pediatrics, University of Utah, Salt Lake City, the author of an accompanying commentary, notes that a lack of research demonstrating how examinations for occult fractures help the child medically or legally may contribute to this lack of skeletal surveys in suspected abuse victims.

"Unfortunately, current systems of child protection ask pediatricians to perform and disclose medical interventions without the return of outcome data needed to evaluate the effectiveness of these interventions," Dr Campbell writes.

"Although study after study suggests that this skeletal survey may describe an unhappy collection of classic metaphyseal lesions and healing rib fractures, not a single study suggests that this skeletal survey will contribute to immediate health or long-term well-being in this child. No study reveals how often occult fractures require surgical intervention, and no study reveals how often occult fractures provide the critical evidence to assure a child’s protection by caregivers, caseworkers, judges, or juries," Dr Campbell writes.

In the current study, the researchers analyzed data from the Premier Perspective Database to examine inpatient and emergency department encounters with children younger than 2 years diagnosed with physical abuse or infants younger than 1 year with non-motor-vehicle injuries frequently attributed to abuse, specifically traumatic brain injury and femur fracture.

The authors found racial and socioeconomic disparities between children who received skeletal surveys and those who did not. Black children diagnosed with physical abuse were half as likely as white children to undergo an evaluation (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.36 - 0.64), Hispanic children were nearly twice as likely as white children to undergo evaluation (OR, 1.09; 95% CI, 0.68 - 1.76), and children of other ethnicities were slightly less likely than white children to be evaluated (OR, 0.79; 95% CI, 0.61 - 1.03).

Infants with traumatic brain injury were more likely to evaluated if they had government insurance (OR, 2.38; 95% CI, 1.73 - 3.25) compared with those with private insurance.

Hospitals that cared for higher volumes of young, injured children were more likely to evaluate for occult fractures in children with a diagnosis of abuse or with injuries associated with a high likelihood of abuse, the study found. Teaching hospitals were more likely to conduct skeletal screening than nonteaching hospitals (OR, 1.59; 95% CI, 1.15 - 2.20). Hospitals in the South (OR, 1.72; 95% CI, 1.14 - 2.59) were more likely to conduct a skeletal survey than those in the Midwest for children diagnosed with physical abuse, followed by those in the West (OR, 1.30; 95% CI, 0.81 - 2.09).

Children younger than 1 years with a diagnosis of physical abuse were more likely to undergo evaluation (OR, 2.79; 95% CI, 2.30 - 3.37) than those between ages 1 and 2 years.

Both the American Academy of Pediatrics and the American College of Radiology recommend skeletal surveys in children with an abuse diagnosis or with injuries often associated with abuse. Authors of the Pediatrics study advocate for "a more standardized approach" to skeletal evaluations.

"Over the past 25 years, research has repeatedly highlighted missed opportunities to evaluate and diagnose abuse in young, injured children suffering from undiagnosed injuries as well as ongoing abuse," the authors write. "Research has also revealed that racial and [socioeconomic status–based] biases influence decision-making regarding child abuse evaluations and diagnoses." A guideline calling for universal occult fracture evaluation could eliminate racial and socioeconomic disparities and increase detection of abuse, the authors write.

"The marked variation in occult fracture evaluation rates among infants with high-risk injuries raises concerns for missed opportunities to detect abuse and protect children. These results highlight an opportunity to improve quality of care for this vulnerable population," the authors conclude.

The authors have disclosed no relevant financial relationships. Dr Campbell has disclosed that her institution receives financial compensation for expert witness testimony in suspected child abuse cases for which she has been subpoenaed to testify.

Medscape Medical News > Neurology

Secondhand Smoke Raises Stroke Risk

Pauline Anderson

July 13, 2015

Exposure to secondhand smoke (SHS) raises the risk for stroke by about 30%, which is independent of demographic characteristics, socioeconomic factors, smoking history, Framingham Stroke risk factors, and C-reactive protein (CRP) concentration, new research showed.

These findings "add to the body of evidence supporting stricter smoking regulations," said the authors, who noted that SHS is concerning as 18% of the US adult population smokes.

The study, led by Angela Malek, PhD, Department of Public Health Sciences, Medical University of South Carolina, Charleston, was published online June 16 in the American Journal of Preventive Medicine.

The overall stroke analysis included 21,743 participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, a national, population-based longitudinal study investigating cardiovascular disease and mortality among white and African American adults aged 45 years and older.

Current smokers were excluded from the analysis. SHS exposure was assessed by duration and frequency. Exposure to SHS was defined as more than 1 hour per week in close contact with a smoker (anything less was deemed as not exposed).

Almost a quarter (23%) of study participants reported SHS exposure in the past year and 77% reported no SHS exposure. Those reporting exposure were significantly younger and more likely to be white, to be female, and to have lower education levels than those without exposure.

History of cardiovascular disease, atrial fibrillation, left ventricular hypertrophy, Framingham Stroke Risk Score, and region of residence (Stroke Belt vs non–Stroke Belt) did not differ significantly between the exposed and nonexposed groups.

Of the 5081 participants reporting SHS exposure, 53% were former smokers. About 44% of those without SHS exposure were former smokers.

During an average follow-up of 5.6 years, there were 428 stroke events: 352 ischemic strokes, 50 hemorrhagic strokes, and 26 strokes of unknown subtype.

In unadjusted models, the risk for stroke did not differ significantly between those exposed to SHS and those without exposure. However, after adjustment for demographic and socioeconomic status (SES) covariates, SHS exposure was associated with increased risk for stroke (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.03 - 1.65) among nonsmoking participants.

Further adjustment did not change the HRs meaningfully, although after adjustment for lifestyle factors, statistical significance was lost.

The stroke subtype analyses included 21,717 participants. After adjustment for demographic and SES covariates, the HR for ischemic stroke was 1.29 (95% CI, 1.00 - 1.68).

There was no association between SHS exposure and hemorrhagic stroke.

Although these findings are consistent with results of some previous studies, other research did not find associations between SHS exposure and stroke. According to the authors, earlier studies were limited in that they were prospective, varied in adjustment for potential confounders, had inconsistent definitions of stroke and SHS exposure, had differing measurement and sources of SHS exposure, used inconsistent assessment of stroke subtypes, and were underpowered by inadequate sample size.

Limitations of the current study are that it lacked cotinine measures to validate SHS exposure and used self-reports to classify prevalent stroke and transient ischemic attack. In addition, statistical power to examine the risk for SHS exposure by stroke subtype may have been limited. The null findings for an association between exposure and hemorrhagic stroke may be due to the small numbers of such strokes.

The authors have disclosed no relevant financial relationships.

Am J Prev Med. Published online June 16, 2015. Abstract

Medscape Medical News

Most US Physicians Still Work in Small Practices

Megan Brooks

July 13, 2015

Most physicians in the United States continue to work in small practices despite the challenging healthcare working environment, according to an updated Policy Research Perspectives from the American Medical Association (AMA). "These data show that the majority (60.7%) of physicians were in small practices of 10 or fewer physicians, and that practice size changed very little between 2012 and 2014 in the face of profound structural reforms to healthcare delivery," AMA president-elect Andrew W. Gurman, MD, says in a news release.

But the percentage is down markedly from 30 years ago, when more than three quarters of doctors worked in the small practice setting, the report notes. "It is clear that physician practice has undergone marked changes over the past 30 years," the report says.

AMA senior economist Carol K. Kane, PhD, assessed practice arrangements of physicians in 2014 and changes in work arrangements that occurred between 2012 and 2014 using data from the AMA's Physician Practice Benchmark Surveys. The surveys compose a nationally representative sample of postresidency physicians who provided at least 20 hours of patient care per week, were not employed by the federal government, and practiced in one of the 50 states or the District of Columbia.

Where possible, Dr Kane compared the current data with those from 30 years ago, which turned up some "dramatic" changes.

Owner or Employee?

According to the report, in 2014, 50.8% of physicians were owners of their practices, down slightly from 53.2% in 2012 but well below what it was in 1983, when 76.1% of physicians owned their practices.

Forty-three percent of physicians were employed by their practice in 2014, and 6.2% had a contract with their practice. Since the mid-1980s, the contractor percentage has been in the 4% to 7% range, with no discernable trend either upward or downward, the report says.

In 2012 and 2014, single specialty practice was the most common practice type, with 42% of physicians in single specialty practices in 2014, down slightly from 45.5% in 2012. "Second, and growing, was multi-specialty practice," with 25% of physicians in this practice type in 2014, up from 22.1% in 2012, the report notes.

More physicians worked directly for a hospital or in practices that had at least some hospital ownership in 2014 than in 2012 (32.8% vs 29%). The share of physicians directly employed by a hospital rose from 5.6% in 2012 to 7.2% in 2014; the share of physicians in practices with at least some hospital ownership increased from 23.4% to 25.6%.

Practice size changed very little between 2012 and 2014. In 2014, 22.3% of physicians were in practices of two to four doctors, up by slightly more than 2 percentage points from 2012. This was the biggest change, and the only one that was statistically significant across six size categories, the report notes.

In 2014, 20% of physicians were in practices of five to 10 physicians (about 2 percentage points lower than in 2012), 12.1% were in practices of 11 to 24 doctors, 6.3% in practices with 25 to 49 doctors, and 13.5% practiced with 50 or more physicians.

"Although recent changes in practice size have been minimal, there are marked differences from the mid-1980s," the report notes, with a smaller share of physicians now working in practices with 10 or fewer physicians than in 1983 (60.7% vs 79.6%).

The share of physicians in solo practice fell from 18.4% in 2012 to 17.1% in 2014 and is down from more than 40% in 1983.

The AMA is "committed to ensuring physicians in all practice sizes and types can thrive and offers innovative strategies and resources that address common practice challenges in the new health environment," Dr Gurman said in the release.

The updated Policy Research Perspectives is available on the AMA's website.

Medscape

WebMD Health News

Obama Urges Support for Older Americans

Bara Vaida

July 13, 2015

President Barack Obama pledged on Monday to do more to improve the lives of aging Americans and their families through a host of new rules and programs aimed at helping senior citizens save money for retirement, supporting caregivers of aging relatives and cracking down on elder abuse.

“It’s about our commitment to each other and respecting everyone’s value, no matter how young or old you are,” said Obama in a speech to hundreds of attendees of the 2015 White House Conference on Aging. “That’s how we’ll build a better future for our parents, our families, ourselves — and our country.”

About one-third of American workers don’t have access to an employer retirement plan, Obama said. However, a handful of states have passed laws to create new ways for those people to save for retirement, and about 20 other states are considering the idea, he said.

The administration has called on the Department of Labor to clarify federal regulations and “create a clear path forward for states to create retirement savings programs,” Obama said. “... If every state did this, tens of millions more Americans could save for retirement at work.”

He called it “perverse” that it’s easier for those with money to save money. “We have to make it easier for everyone.”

To help millions of Americans who have become caregivers of aging relatives or friends, the administration also announced it has launched aging.gov, a new website that can connect people with local services and support.

The administration also plans to spend $ 35 million to train more health care workers in dementia care, and will overhaul regulations governing the quality of the nation’s 15,000 nursing homes.

In addition, Obama said the Department of Justice would do more to train prosecutors to pursue more elder abuse and financial exploitation cases.

And he said he will push Congress to pass legislation reauthorizing the Older Americans Act. The law funds services for older adults such as meals, job training, senior centers, transportation and caregiver support. Its authorization expired in 2011

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• US and Europe Differ on Use of Vaptans in HyponatremiaMedscape Medical News Lisa NainggolanThe UK doctors union, the British Medical Association (BMA), is calling for a tax of 20% to be added to the cost of sugar-sweetened beverages, which could then be used to subsidize the price of fruit and vegetables, as part of a sustained attempt to improve the quality of the UK diet.If collaborative policies to reduce consumption of salt, trans fats, saturated fats, and sugars do not hit target within the next few years, mandatory regulations to limit intake should be instituted, it argues."Central to this is creating an environment where it is normal, easy, and enjoyable for children and young people to eat healthily," she noted.There have previously been calls in the United Kingdom for a "sugar tax," but the government has so far resisted introducing such legislation.Rather, the way forward is to work collaboratively with government, says the organization, which represents UK food and drinks manufacturers. "We welcome [the UK government] recently unequivocally ruling out a sugar tax and committing to a partnership approach to public health," said Ian Wright, director general of the Food and Drink Federation, in a statement.The BMA recognizes this in its report, noting that "as one of the first European countries to develop a national salt-reduction strategy, some progress has been made in the UK in reducing the salt content of many processed foods and in reducing average salt intakes.""Regulatory measures should be considered if these targets are not met.""A 1-year target should now be set for industry to eliminate artificial trans fats from all products sold in the UK, with legislation introduced if this target is not met."And for well over a decade, UK producers have voluntarily provided clear nutrition information on packaging, he added, with the food industry "helping health professionals to encourage people to use the information provided."Poor Diet: More Disease Than Smoking, Inactivity, and Alcohol Combined Indeed, worldwide, poor diet "contributes to more disease than physical inactivity, smoking, and alcohol combined. The burden of diet-related ill health in the UK is substantial, estimated to lead to 70,000 premature deaths annually, which represents around 12% of the total number of deaths, and costs the NHS around ￡6 billion per year," it continues.As well as calling for legislation in certain areas, including a prohibition on the mass marketing of unhealthy foods, the report calls for improvement in education and health promotion, including clearer labeling on food products for consumers.The aim is to create an environment "where dietary choices default to healthy options," it concludes.
• Medscape Medical News > Psychiatry
• It also calls for legislation to ensure only healthy food is available in schools and hospitals and that the "sale of all unhealthy food and drink products should be phased out in all NHS hospitals."
• The report therefore urges comprehensive action to promote healthier diets among children and young people and particularly among individuals from low socioeconomic classes.
• The BMA report stresses that an unhealthy dietary pattern "is strongly associated and causally linked with a number of chronic, complex conditions such as obesity, cardiovascular disease, cancer, and type 2 diabetes."
• But Prof Hollins argues this is not enough: "It is not uncommon for reports like this to elicit cries of 'nanny state' and forceful objections that governments have no place in telling people how to live their lives. This view needs to be squarely challenged. My belief is that it is commercial interests that are excessively influencing people's decisions about their diet," she asserted.
• Mr Wright said: "British food and drink companies are cutting the salt, saturates, and calories in their products, which are offered in a range of portion sizes. They have virtually eliminated artificial trans fats in UK products."
• And with regard to trans fats, the same approach has been taken, "but the introduction of mandatory limits has been found to be the most effective strategy in other countries," says the BMA.
• But there is still a way to go, it stresses. As mean salt intake for adults and children remains above recommended levels and previous voluntary salt-reduction targets have not been met, a target should be set to achieve the recommended maximum population intake of 6 g [about 2.4 g of sodium] per day by 2017, it adds.
• The United Kingdom has already managed to reduce the amount of salt in many processed foods through a collaborative process with industry rather than any mandatory requirement.
• In response to the BMA call, the UK Food and Drink Federation notes that both Belgium and Denmark rejected the notion of a tax in 2013, "and evidence from France shows that while sales of soft drinks initially fell after a tax was introduced in 2012, they have increased since."
• To Legislate or Not? That Is the Question
• Author of the report, BMA board of science chair Prof Sheila Hollins, a former GP and a psychiatrist, said, "I am particularly distressed that poor diet is such a feature of the lives of our children and young people. We should not tolerate that the next generation is growing up with the normality of regularly consuming processed and fast food or that there are children who have no concept of where their food comes from.
• In a new report, entitled "Food for Thought: Promoting Healthy Diets Among Children and Young People," the BMA says: "Doctors are increasingly concerned about the impact of poor diet on the nation's health. This is not only a significant cause of ill health and premature mortality, but a considerable drain on National Health Service (NHS) resources."
• July 13, 2015
• British Medical Association Calls for 20% Sugar Tax on Sodas
• Return to Article

OCD Relapse After CBT: Mystery Solved?

Liam Davenport

July 13, 2015

Higher baseline brain connectivity may explain why a significant proportion of patients with obsessive-compulsive disorder (OCD) not only relapse following treatment with cognitive-behavioral therapy CBT) but also experience symptom worsening.

Investigators in the Department of Psychiatry and Biobehavioral Sciences at the Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, note that if confirmed in further studies, these findings could pave the way for personalized treatment in this patient population.

"CBT increases network efficiency as it alleviates symptoms in most patients, but patients entering CBT with already high-network efficiency are at greater risk of relapse," investigators led by Jamie D. Feusner, MD, Semel Institute for Neuroscience and Human Behavior, write.

"Results show functional network efficiency as a biomarker of CBT response and relapse in OCD, which has potential implications for clinical decision-making and treatment selection."

The research was published online May 20 in Frontiers in Psychiatry.

Significant Relapse Rate

Dr Feusner explained that the study came out of a desire to understand the impact of CBT on brain function and brain metabolites in individuals with OCD.

"People with OCD often do well with treatment with cognitive-behavioral therapy, so it is considered one of the first-line treatments, but even though people often do well and the chance of success is fairly high, there's a fair percentage of people that will relapse after the treatment," he told Medscape Medical News.

"So we simply wanted to understand: Are there any ways that might be able to predict who are these people that are likely to do worse in the follow-up period and whose symptoms are likely to worsen by brain connectivity patterns, either before treatment or after treatment, or even as a result of treatment?"

"Ideally," he added, "we'd like to identify something that is a signature of their brain connectivity before treatment that could help ultimately with clinical decision-making."

The team performed resting-state functional magnetic resonance imaging in 17 adults with OCD before and after 4 weeks of intensive CBT, which consisted of 90-minute sessions 5 days per week.

Functional connectivity data were collated for graph theory metrics so that the mean clustering coefficient, global efficiency, small worldness, and modularity for 160 functionally defined nodes of brain networks could be calculated. From this, pre- and posttreatment brain connectivity could be established.

The participants also completed a battery of assessments, comprising the Yale-Brown Obsessive-Compulsive Scale (YBOCS), the Montgomery-?sberg Depression Rating Scale (MADRS), the Hamilton Anxiety Scale (HAMA), the Sheehan Disability Scale, and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form (Q-LES-Q), with the results tallied to the findings on brain imaging.

The results indicated that mean OCD symptom scores decreased by 40.4% ± 16.4% between pre- and posttreatment assessments, with 64.7% of patients responding and 58.8% remitting. However, 35.3% of patients experienced clinically significant worsening during follow-up.

Between the pre- and posttreatment assessments, there was a significant increase in small worldness, and modularity decreased significantly (P = .012 for both).

Interestingly, further analysis revealed that pretreatment small worldness was significantly associated with changes in YBOCS scores at follow-up (P = .004), such that a higher degree of small worldness was associated with worsening YBOCS scores. The effect persisted after adjusting for multiple comparisons.

None of the measures of brain interconnectedness were associated with HAMA, MADRS, Q-LES-Q, or Sheehan scores.

Important First Step

Discussing what appear on the surface to be the counterintuitive findings in individuals with higher pretreatment small-world connectivity, Dr Feusner said that one possible explanation is that the treatment itself could involve reorganization of brain networks.

"Generally, people who are going through this therapy develop a much better understanding of the totality of their symptoms and how they interact with each other," he said.

"For example, they understand how the symptom is triggered in themselves, whether it's a sensory trigger or thought trigger; they understand what emotions they experience as a result of it, and they understand what behaviors they are going to do," Dr Feusner added.

"They also understand, when they do the behaviors, how that impacts back on the obsessive thoughts, and they are much better able to recognize when they're getting obsessive thoughts, as opposed to it being a true and a real danger."

"What we're thinking is that for people already with very-high-network efficiency, these may be people who are already aware of these things, they already have a good integration of their sensory, emotional, and cognitive experiences, and so it may be that...despite having that high level of integration and maybe high-network efficiency, they're still severe, so they may represent a more intractable group," he added.

Although this would need to be confirmed in future studies with serial imaging and other clinical and cognitive measures, Dr Feusner believes that potentially, the brain reorganization needs to occur at the same time as symptom reductions for the effect of treatment to be maintained.

"If their brains are already maximally efficient, there isn't room for reorganization, and so in those people, even though they temporarily may experience symptom reduction, it doesn't stick because it didn't happen contemporaneously with this network reorganization," he explained.

Noting that there were a large number of unknowns with this study population, Dr Feusner emphasized that it was nevertheless an important first step in establishing which individuals with OCD will benefit from CBT.

"Right now, it's more that we're looking at group-level associations, but the next question that needs to be answered with further analysis and maybe further studies is, What is the ability on an individual subject level to take a person and do a brain scan, and what is the positive predictive value and negative predictive value of a certain result on their symptom improvement or worsening?"

"Mostly likely it won't be one factor that will be the most useful to use as predictive values. It will probably be a combination of factors. We happen to have found one in the study that was fairly highly predictive."

"It explained about 60% of the variance, which is quite high, but we can probably do better than that, and we may need to do better than that when it gets to the point of taking an individual person with OCD and trying to predict if they're going to do better or worse."

The research was funded by a grant from the National Institute of Mental Health. The authors have disclosed no relevant financial relationships.

Front Psychiatry. Published online May 20, 2015. Full text