Study provides roadmap for delirium risks, prevention, treatment, prognosis and research

INDIANAPOLIS -- Delirium, a common acute condition with significant short- and long-term effects on cognition and function, should be identified as an indicator of poor long-term prognosis, prompting immediate and effective management strategies, according to the authors of a new systematic evidence review ceus for nurses "Delirium is extremely common among older adults in intensive care units and is not uncommon in other hospital units and in nursing homes, but too often it's ignored or accepted as inevitable. Delirium significantly increases risk of developing dementia and triples likelihood of death. It can't be ignored," said Regenstrief Institute investigator Babar A. Khan, M.D., M.S., assistant professor of medicine at the Indiana University School of Medicine and an Indiana University Center for Aging Research scientist, the first author of the review. The authors reviewed 45 years of research encompassing 585 studies to provide a roadmap for the identification of risks, prevention and treatment options as well as prognoses related to delirium. "As an intensive care unit physician, I have seen that about 80 percent of ICU patients who need mechanical assistance to breathe develop delirium," Dr. Khan said. "That's because in addition to being on a respirator, they have multiple risk factors that can predispose and precipitate delirium, including but not limited to serious illness, restraints and pre-existing cognitive impairment." According to the American Delirium Society, more than 7 million hospitalized Americans suffer from delirium each year, and more than 60 percent of delirium cases are not recognized or treated. "Having delirium prolongs the length of a hospital stay, increases the risk of post-hospitalization transfer to a nursing home, increases the risk of death and may lead to permanent brain damage," said Regenstrief Institute investigator Malaz Boustani, M.D., MPH, associate professor of medicine at IU School of Medicine and associate director of the IU Center for Aging Research. Dr. Boustani, senior author of the new study, is medical director of the Wishard Healthy Aging Brain Center and president of the American Delirium Society. How to lower the likelihood of delirium and increase recognition of cases that occur? Drs. Khan and Boustani recommend eliminating restraints, treating depression, ensuring that patients have access to eyeglasses and hearing aids, and prescribing classes of antipsychotics that do not negatively affect the aging brain. They and the other study authors note the need for a more sensitive screening tool for delirium, especially when administered by a non-expert. "Delirium in Hospitalized Patients: Implications of Current Evidence on Clinical Practice and Future Avenues for Research -- A Systematic Evidence Review" was published in the September issue of Journal of Hospital Medicine. In addition to presenting evidence for clinical practice, it identifies areas for future delirium research. ### The study was supported by the National Institute on Aging (grant AG054205-02) and the National Institute of Mental Health (grant MH080827-04). In addition to Drs. Khan and Boustani, authors of the paper are Mohammed Zawahiri, M.D., of the Regenstrief Institute and IU Center for Aging Research; Regenstrief Investigator Noll L. Campbell, Pharm.D., of Purdue University and Wishard Health Services; George C. Fox, M.D., MRCPsych, University of East Anglia, Norfolk, U.K.; Eric J. Weinstein, M.D., of Tri-State Pulmonary Associates, Cincinnati, Ohio; Arif Nazir, M.D., Mark O. Farber, M.D., and John D. Buckley, M.D., MPH, of the IU School of Medicine; and Alasdair MacLullich, Ph.D., of the University of Edinburgh.

Simple tool may help evaluate risk for violence among patients with mental illness

Mental health professionals, who often are tasked with evaluating and managing the risk of violence by their patients, may benefit from a simple tool to more accurately make a risk assessment, according to a recent study conducted at the University of California, San Francisco. The research, led by psychiatrist Alan Teo, MD, when he was a UCSF medical resident, examined how accurate psychiatrists were at evaluating risk of violence by acutely ill patients admitted to psychiatric units. The first part of the study showed that inexperienced psychiatric residents performed no better than they would have by chance, whereas veteran psychiatrists were moderately successful in evaluating their patients' risk of violence. However, the second part of the study showed that when researchers applied the information from the "Historical, Clinical, Risk Management󈞀–Clinical" (HRC-20-C) scale – a brief, structured risk assessment tool – to the patients evaluated by residents, accuracy in identifying their potential for violence increased to a level nearly as high as the faculty psychiatrists', who had an average of 15 years more experience. "Similar to a checklist a pilot might use before takeoff, the HRC-20-C has just five items that any trained mental health professional can use to assess their patients," Teo said. "To improve the safety for staff and patients in high-risk settings, it is critical to teach budding psychiatrists and other mental health professionals how to use a practical tool such as this one." The study was published Aug. 31 in the journal Psychiatric Services. The HCR-20-C was developed several years ago by researchers in Canada, where it is used in a number of settings such as prisons and hospitals. However, in the United States, structured tools such as the HCR-20-C are only beginning to be used in hospitals. "This is the first study to compare the accuracy of risk assessments by senior psychiatrists to those completed by psychiatric residents," said senior author Dale McNiel, PhD, UCSF professor of clinical psychology. "It shows that clinicians with limited training and experience tend to be inaccurate in their risk assessments, and that structured methods such as HCR-20-C hold promise for improving training in risk assessment for violence." "The UCSF study was unusual," Teo added, "in applying a shorter version of the tool that could be more easily incorporated into clinical practice." Teo and his team assessed the doctors' accuracy by comparing the risk assessments that they made at the time patients were admitted to the hospital, to whether or not patients later became physically aggressive toward hospital staff members, such as by hitting, kicking or biting. The study included 151 patients who became violent and 150 patients who did not become violent mhc continuing education The patients in the study had severe mental illnesses, often schizophrenia, and had been involuntarily admitted to the hospital. ### The study was partly supported by the National Institute of Mental Health, a Minority Fellowship sponsored by the American Psychiatric Association and the Clinical and Translational Science Award from the National Institute of Health (NIH). When this study was conducted, all of the authors were affiliated with the UCSF Department of Psychiatry. Teo now is with the Department of Psychiatry, University of Michigan, Ann Arbor, and Sarah Holley, PhD, a co-author, now is with the Department of Psychology, San Francisco State University. Mark Leary, MD, of the UCSF Department of Psychiatry, also is a co-author. UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.

Should I marry him?

If you're having doubts, don't ignore them, suggests UCLA psychology study By Stuart WolpertSeptember 13, 2012 Doubt is not a pleasant mental state, but certainty is a ridiculous one. —Voltaire In the first scientific study to test whether doubts about getting married are more likely to lead to an unhappy marriage and divorce, UCLA psychologists report that when women have doubts before their wedding, their misgivings are often a warning sign of trouble if they go ahead with the marriage. The UCLA study demonstrates that pre-wedding uncertainty, especially among women, predicts higher divorce rates and less marital satisfaction years later. "People think everybody has premarital doubts and you don't have to worry about them," said Justin Lavner, a UCLA doctoral candidate in psychology and lead author of the study. "We found they are common but not benign. Newlywed wives who had doubts about getting married before their wedding were two-and-a-half times more likely to divorce four years later than wives without these doubts. Among couples still married after four years, husbands and wives with doubts were significantly less satisfied with their marriage than those without doubts. "You know yourself, your partner and your relationship better than anybody else does; if you're feeling nervous about it, pay attention to that," he added. "It's worth exploring what you're nervous about." The psychologists studied 464 newlywed spouses (232 couples) in Los Angeles within the first few months of marriage and conducted follow-up surveys with the couples every six months for four years. At the time of marriage, the average age of the husbands was 27, and the average age of the wives was 25. The research is published in the online version of the Journal of Family Psychology, published by the American Psychological Association, and will appear in an upcoming print edition. When asked, "Were you ever uncertain or hesitant about getting married?" at their initial interview, 47 percent of husbands and 38 percent of wives said yes. Yet while women were less likely than men to have doubts, their doubts were more meaningful in predicting trouble after the wedding, the researchers found. Among women, 19 percent of those who reported pre-wedding doubts were divorced four years later, compared with 8 percent of those who did not report having doubts. For husbands, 14 percent who reported premarital doubts were divorced four years later, compared with 9 percent who did not report having doubts. Doubt proved to be a decisive factor, regardless of how satisfied the spouses were with their relationships when interviewed, whether their parents were divorced, whether the couple lived together before the wedding and how difficult their engagement was. In 36 percent of couples, the husband and wife had no doubts about getting married. Of those couples, 6 percent got divorced within four years. When only the husband had doubts, 10 percent of the couples got divorced. When only the wife had doubts, 18 percent of couples got divorced. When both partners had doubts, 20 percent of the couples got divorced. "What this tells us," Lavner said, "is that when women have doubts before their wedding, these should not be lightly dismissed. Do not assume your doubts will just go away or that love is enough to overpower your concerns. There's no evidence that problems in a marriage just go away and get better. If anything, problems are more likely to escalate." Thomas Bradbury, a UCLA psychology professor and co-author of the study, compared the situation to finding something disturbing on your skin that you hadn't noticed before. "If you see something unusual on your skin, should you ignore it and go to the beach, or see a doctor? Be smart and don't ignore it — and don't ignore your doubts either," said Bradbury, who co-directs the Relationship Institute at UCLA. "Have a conversation and see how it goes. Do you think the doubts will go away when you have a mortgage and two kids? Don't count on that." The psychologists are not advising women with doubts to necessarily end the relationship, they say. "Talk about it and try to work through it," Bradbury said. "You hope that the big issues have been addressed before the wedding." Benjamin Karney, a UCLA professor of psychology and co-director of the Relationship Institute at UCLA, was a co-author of the study. The research was federally funded by the National Institute of Mental Health (part of the National Institutes of Health) and the National Science Foundation, as well as by UCLA's Academic Senate continuing education for MFTs UCLA is California’s largest university, with an enrollment of nearly 38,000 undergraduate and graduate students. The UCLA College of Letters and Science and the university’s 11 professional schools feature renowned faculty and offer 337 degree programs and majors. UCLA is a national and international leader in the breadth and quality of its academic, research, health care, cultural, continuing education and athletic programs. Six alumni and five faculty have been awarded the Nobel Prize. For more news, visit the UCLA Newsroom and follow us on Twitter.

Studying sex differences in autism focus of $15 million NIH award to Yale center

The reasons why autism spectrum disorders are almost five times more common among boys than among girls may soon be revealed, thanks to a five-year, $15 million National Institutes of Health (NIH) grant awarded to Yale School of Medicine for the Autism Centers of Excellence (ACE) research program. Led by principal investigator Kevin Pelphrey of Yale Child Study Center, the Yale ACE award is part of a $100 million National Institutes of Health grant to nine institutions investigating sex differences in autism spectrum disorders, or ASD, as well as studying ASD and limited speech. Pelphrey and a collaborative team of researchers from Yale, UCLA, Harvard, and the University of Washington, will investigate the poorly understood nature of autism in females. The team will study an unprecedented number of girls with autism and will focus on genes, brain function, and behavior throughout childhood and adolescence. The objectives are to identify causes of autism and develop novel treatments.

ASDs are complex developmental disorders that affect how a person behaves, interacts with others, communicates, and learns. According to the Centers for Disease Control and Prevention, ASD affects approximately 1 in 88 children in the United States. "This award represents an innovative collaboration among three laboratories at Yale led by Drs. Matthew State, James McPartland, and myself," said Pelphrey, the Harris Associate Professor in the Child Study Center, and associate professor of psychology, and director of the Child Neuroscience Laboratory. "It is my hope that this award will invigorate research in autism at Yale and allow us to maintain our outstanding history of cutting edge work in this field." Alcoholism and Drug Abuse Counselors Continuing Education ### NIH created the ACE Program in 2007 to launch an intense and coordinated research program into the causes of ASD and to find new treatments. The program supports large collaborative efforts to advance the broad research goals. The program expanded this year to examine such issues as children and adults who have limited or no speech, possible links between ASD and other genetic syndromes, potential treatments, and the possible reasons why ASDs are more common among boys than girls, according to Alice Kay of the Intellectual and Developmental Disabilities Branch at the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), one of five institutes funding the ACE program. In addition to the NICHD, the NIH institutes that support the ACE program are the National Institute on Deafness and Other Communication Disorders, the National Institute of Environmental Health Sciences, the National Institute of Mental Health and the National Institute of Neurological Disorders and Stroke. The eight other researchers to receive ACE funding hail from the following institutions: University of California, Emory University, Boston University, University of North Carolina at Chapel Hill, Mount Sinai School of Medicine, and Harvard Medical School. *Research reported here was supported by the National Institute Of Mental Health (NIMH) of the National Institutes of Health under Award Number R01MH100028.

Simple tool may help inexperienced psychiatrists better predict violence risk in patients, U-M study finds

Without assessment tool, inexperienced psychiatrists less likely to accurately predict violence ANN ARBOR, Mich. Inexperienced psychiatrists are less likely than their veteran peers to accurately predict violence by their patients, but a simple assessment checklist might help bridge that accuracy gap, according to new research from the University of Michigan. Led by psychiatrist Alan Teo, M.D., a Robert Wood Johnson Foundation Clinical Scholar of the University of Michigan, researchers examined how accurate psychiatrists were at predicting assaults by acutely ill patients admitted to psychiatric units. Their results found that inexperienced psychiatric resident doctors did no better than a coin flip, whereas veteran psychiatrists were 70 percent accurate in predicting risk of violence. However, when a brief risk assessment tool was applied to the cases that the junior doctors evaluated, their level of accuracy jumped to 67 percent, or nearly as good as the more experienced psychiatrists. Results of the research were published online Sept. 1 in the journal Psychiatric Services. “The tool we used, called the HCR-20-C, is remarkably brief and straightforward. Like a checklist a pilot might use before takeoff, it has just five items that any trained mental health professional can assess,” Teo says. In light of recent violent events, such as the movie theater shooting in Aurora, Colo,, earlier this summer, Teo says predicting violence risk in psychiatric patients is an increasingly important topic. “Given public concern about this issue, I think teaching our budding psychiatrists and others how to use a practical tool like this, and encouraging its use in high-risk settings is a no-brainer,” he says. In the study, researchers were able to assess doctors’ accuracy by comparing patients who had assaulted hospital staff members with similar patients who had not been violent. Because all patients received a threat assessment when admitted to the psychiatric unit, the researchers were able to compare a patient’s predicted violence risk with whether they actually had a documented assault while in the hospital. Incidents of physical aggression typically included punching, slapping, or throwing objects, as well as yelling, directed at staff members of the hospital. The patients studied had severe illnesses, often schizophrenia, and had been involuntarily admitted to the hospital. Teo says this study is the first to compare the predictive success of violence assessment between experienced and inexperienced psychiatrists. The results, he says, highlight the importance of emphasizing violence risk assessment in clinical training programs ceus for counselors “If trainees are indeed less able than trained and experienced clinicians to accurately perform risk assessments for violence, it’s important to figure out a way to improve their accuracy,” he says. “Our study shows that evidence-based structured tools might have the potential to augment training and improve risk assessment.” ### Citation: Psychiatric Services, Sept. 1, 2012; doi: 10.1176/appi.ps.201200019 Other authors: Sarah R. Holley, Ph.D.; Mary Leary, M.D.; Dale E. McNiel, Ph.D. Conflicts of interest: None. Funding: This work was partly supported by the National Institute of Mental Health (grant R25 MH060482), a Minority Fellowship sponsored by the American Psychiatric Association and the Substance Abuse and Mental Health Services Administration, and a Clinical and Translational Science Award (ULI RR024131) from the National Institutes of Health.

That giant tarantula is terrifying, but I'll touch it

Expressing your emotions can reduce fear, UCLA psychologists report "Give sorrow words." —Malcolm in Shakespeare's "Macbeth" Can simply describing your feelings at stressful times make you less afraid and less anxious? A new UCLA psychology study suggests that labeling your emotions at the precise moment you are confronting what you fear can indeed have that effect. The psychologists asked 88 people with a fear of spiders to approach a large, live tarantula in an open container outdoors. The participants were told to walk closer and closer to the spider and eventually touch it if they could. The subjects were then divided into four groups and sat in front of another tarantula in a container in an indoor setting. In the first group, the subjects were asked to describe the emotions they were experiencing and to label their reactions to the tarantula — saying, for example, "I'm anxious and frightened by the ugly, terrifying spider." "This is unique because it differs from typical procedures in which the goal is to have people think differently about the experience — to change their emotional experience or change the way they think about it so that it doesn't make them anxious," said Michelle Craske, a professor of psychology at UCLA and the senior author of the study. "Here, there was no attempt to change their experience, just to state what they were experiencing." In a second group, the subjects used more neutral terms that did not convey their fear or disgust and were aimed at making the experience seem less threatening. They might say, for example, "That little spider can't hurt me; I'm not afraid of it." "This is the usual approach for helping individuals to confront the things they fear," Craske said. In a third group, the subjects said something irrelevant to the experience, and in a fourth group, the subjects did not say anything — they were simply exposed to the spider. All the participants were re-tested in the outdoor setting one week later and were again asked to get closer and closer to the tarantula and potentially touch it with a finger. The researchers measured how close subjects could get to the spider, how distressed they were and what their physiological responses were, focusing in particular on how much the subjects' hands sweated, which is a good measure of fear, Craske said. The researchers found that the first group did far better than the other three. These people were able to get closer to the tarantula — much closer than those in the third group and somewhat closer than those in the other two groups — and their hands were sweating significantly less than the participants in all of the other groups. The results are published in the online edition of the journal Psychological Science and will appear in an upcoming print edition. "They got closer and they were less emotionally aroused," Craske said. "The differences were significant. The results are even more significant given the limited amount of time involved. With a fuller treatment, the effects may be even larger. "Exposure is potent," she added. "It's surprising that this minimal intervention action had a significant effect over exposure alone." So why were the people in the first group — those who performed what the life scientists call "affect labeling" — able to get closer to the tarantula? "If you're having less of a threat response, which is indicated by less sweat, that would allow you to get closer; you have less of a fear response," said study co-author Matthew Lieberman, a UCLA professor of psychology and of psychiatry and biobehavioral sciences. "When spider-phobics say, 'I'm terrified of that nasty spider,' they're not learning something new; that's exactly what they were feeling — but now instead of just feeling it, they're saying it. For some reason that we don't fully understand, that transition is enough to make a difference." The scientists also analyzed the words the subjects used. Those who used a larger number of negative words did better, in terms of both how close they were willing to get to the tarantula and their skin-sweat response. In other words, describing the tarantula as terrifying actually proved beneficial in ultimately reducing the fear of it. "Doing more affect labeling seemed to be better," Lieberman said. "That is so different from how we normally think about exposure therapy, where you try to get the person to think differently, to think it's not so bad," Craske said. "What we did here was to simply encourage individuals to state the negative." "We've published a series of studies where we asked people, 'Which do you think would make you feel worse: looking at a disturbing image or looking at that disturbing image and choosing a negative emotional word to describe it,'" Lieberman said. "Almost everyone said it would be worse to have to look at that image and focus on the negative by picking a negative word. People think that makes our negative emotions more intense. Well, that is exactly what we asked people to do here. In fact, it's a little better to have people label their emotions — multiple studies now show this. Our intuitions here are wrong." This is the first study to demonstrate benefits for affect labeling of fear and anxiety in a real-world setting, Craske and Lieberman said. "The implication," Craske said, "is to encourage patients, as they do their exposure to whatever they are fearful of, to label the emotional responses they are experiencing and label the characteristics of the stimuli — to verbalize their feelings. That lets people experience the very things they are afraid and say, 'I feel scared and I'm here.' They're not trying to push it away and say it's not so bad. Be in the moment and allow yourself to experience whatever you're experiencing." Craske and Lieberman are studying how this approach can help people who have been traumatized, such as rape victims and victims of domestic violence. The approach potentially could benefit soldiers returning from war as well. "I'm far more optimistic than I was before this study," Lieberman said. "I'm a believer that this approach can have real benefits for people. "There is a region in the brain, the right ventrolateral prefrontal cortex, that seems to be involved in labeling our feelings and our emotional reactions, and it is also associated with regulating our emotional responses," he said. "Why those two go together is still a bit of a mystery. This brain region that is involved in simply stating how we are feeling seems to mute our emotional responses, at least under certain circumstances." "There's a trend in psychology of acceptance-based approaches — honestly label your feelings. This study has that flavor to it," Craske said. Katharina Kircanski, a former UCLA graduate student and current postdoctoral scholar at Stanford University, is lead author of the study; she conducted this research as a graduate student in Craske's laboratory MHC Ceus ### The research was federally funded by the National Institutes of Health's National Institute of Mental Health, and by the American Psychological Association. UCLA is California's largest university, with an enrollment of nearly 38,000 undergraduate and graduate students. The UCLA College of Letters and Science and the university's 11 professional schools feature renowned faculty and offer 337 degree programs and majors. UCLA is a national and international leader in the breadth and quality of its academic, research, health care, cultural, continuing education and athletic programs. Six alumni and five faculty have been awarded the Nobel Prize.

Predicting how patients respond to therapy

Brain scans could help doctors choose treatments for people with social anxiety disorder CAMBRIDGE, MA -- A new study led by MIT neuroscientists has found that brain scans of patients with social anxiety disorder can help predict whether they will benefit from cognitive behavioral therapy. Social anxiety is usually treated with either cognitive behavioral therapy or medications. However, it is currently impossible to predict which treatment will work best for a particular patient. The team of researchers from MIT, Boston University (BU) and Massachusetts General Hospital (MGH) found that the effectiveness of therapy could be predicted by measuring patients' brain activity as they looked at photos of faces, before the therapy sessions began. The findings, published this week in the Archives of General Psychiatry, may help doctors choose more effective treatments for social anxiety disorder, which is estimated to affect around 15 million people in the United States. "Our vision is that some of these measures might direct individuals to treatments that are more likely to work for them," says John Gabrieli, the Grover M. Hermann Professor of Brain and Cognitive Sciences at MIT, a member of the McGovern Institute for Brain Research and senior author of the paper. Lead authors of the paper are MIT postdoc Oliver Doehrmann and Satrajit Ghosh, a research scientist in the McGovern Institute. Choosing treatments Sufferers of social anxiety disorder experience intense fear in social situations that interferes with their ability to function in daily life. Cognitive behavioral therapy aims to change the thought and behavior patterns that lead to anxiety. For social anxiety disorder patients, that might include learning to reverse the belief that others are watching or judging them. The new paper is part of a larger study that MGH and BU ran recently on cognitive behavioral therapy for social anxiety, led by Mark Pollack, director of the Center for Anxiety and Traumatic Stress Disorders at MGH, and Stefan Hofmann, director of the Social Anxiety Program at BU. "This was a chance to ask if these brain measures, taken before treatment, would be informative in ways above and beyond what physicians can measure now, and determine who would be responsive to this treatment," Gabrieli says. Currently doctors might choose a treatment based on factors such as ease of taking pills versus going to therapy, the possibility of drug side effects, or what the patient's insurance will cover. "From a science perspective there's very little evidence about which treatment is optimal for a person," Gabrieli says. The researchers used functional magnetic resonance imaging (fMRI) to image the brains of patients before and after treatment. There have been many imaging studies showing brain differences between healthy people and patients with neuropsychiatric disorders, but so far imaging has not been established as a way to predict patients' responses to particular treatments CADC I & II Continuing Education Measuring brain activity In the new study, the researchers measured differences in brain activity as patients looked at images of angry or neutral faces. After 12 weeks of cognitive behavioral therapy, patients' social anxiety levels were tested. The researchers found that patients who had shown a greater difference in activity in high-level visual processing areas during the face-response task showed the most improvement after therapy. Gabrieli says it's unclear why activity in brain regions involved with visual processing would be a good predictor of treatment outcome. One possibility is that patients who benefited more were those whose brains were already adept at segregating different types of experiences, Gabrieli says. The researchers are now planning a follow-up study to investigate whether brain scans can predict differences in response between cognitive behavioral therapy and drug treatment. "Right now, all by itself, we're just giving somebody encouraging or discouraging news about the likely outcome" of therapy, Gabrieli says. "The really valuable thing would be if it turns out to be differentially sensitive to different treatment choices." ### The research was funded by the Poitras Center for Affective Disorders Research and the National Institute of Mental Health. Written by Anne Trafton, MIT News Office