Psychosomatics 2015:56:445459

& 2015 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.

Original Research Reports

Updates in Psychosomatic Medicine: 2014
Oliver Freudenreich, M.D., Jeff C. Huffman, M.D., Michael Sharpe, M.D.,
Scott R. Beach, M.D., Christopher M. Celano, M.D., Lydia A. Chwastiak, M.D., M.P.H.,
Mary Ann Cohen, M.D., Anne Dickerman, M.D., Mary Joe Fitz-Gerald, M.D.,
Nicholas Kontos, M.D., Leena Mittal, M.D., Shamim H. Nejad, M.D., Shehzad Niazi, M.D.,
Marta Novak, M.D., Ph.D., med.habil., Kemuel Philbrick, M.D.,
Joseph J. Rasimas, M.D., Ph.D., Jewel Shim, M.D., Scott A. Simpson, M.D., M.P.H.,
Audrey Walker, M.D., Jane Walker, Ph.D., Christina L. Wichman, D.O.,
Paula Zimbrean, M.D., Wolfgang Sllner, M.D., Theodore A. Stern, M.D.

Background: The amount of literature published

annually related to psychosomatic medicine is vast; this
poses a challenge for practitioners to keep up-to-date in
all but a small area of expertise. Objectives: To
introduce how a group process using volunteer experts
can be harnessed to provide clinicians with a manageable selection of important publications in psychosomatic medicine, organized by specialty area, for 2014.
Methods: We used quarterly annotated abstracts
selected by experts from the Academy of Psychosomatic
Medicine and the European Association of

Psychosomatic Medicine in 15 subspecialties to create a

list of important articles. Results: In 2014, subspecialty
experts selected 88 articles of interest for practitioners
of psychosomatic medicine. For this review, 14 articles
were chosen. Conclusions: A group process can be used
to whittle down the vast literature in psychosomatic
medicine and compile a list of important articles for
individual practitioners. Such an approach is consistent
with the idea of physicians as lifelong learners and
educators.
(Psychosomatics 2015; 56:445459)

Received March 5, 2015; revised March 30, 2015; accepted March 31,
2015. From Department of Psychiatry, Massachusetts General
Hospital, Boston, MA (OF, JCH, SRB, CMC, NK, SHN, TAS);
Psychological Medicine Research, Department of Psychiatry, University of Oxford, Oxford, UK (MS, JW); Department of Psychiatry
and Behavioral Sciences, University of Washington School of
Medicine, Seattle, WA (LAC); Department of Psychiatry, The
Icahn School of Medicine at Mount Sinai, New York, NY
(MAC); Department of Psychiatry, Consultation-Liaison Service,
New York-Presbyterian Hospital, Weill Cornell Medical College,
New York, NY (AD); Department of Psychiatry, Louisiana State
University Health Sciences Center, Shreveport, LA (MJF-G.);
Divisions of Medical Psychiatry and Womens Mental Health,
Department of Psychiatry, Brigham and Womens Hospital, Boston,
MA (LM); Department of Psychiatry & Psychology, Mayo Clinic,
Jacksonville, FL (SN); Department of Psychiatry, University
Health Network and University of Toronto, Toronto, Canada
(MN); Institute of Behavioral Sciences, Semmelweis University,
Budapest, Hungary (MN); Department of Psychiatry and

Psychology, Mayo Clinic, Rochester, MN (KP); HealthPartners/

Regions Hospital, St. Paul, MN (JJR); Department of Psychiatry,
Kaiser Oakland Medical Center and the University of California,
San Francisco, San Francisco, CA (JS); Denver Health Medical
Center, University of Colorado School of Medicine, Denver, CO
(SAS); Division of Child and Adolescent Psychiatry, Albert Einstein
College of Medicine/Montefiore Medical Center, Bronx, NY (AW);
Department of Psychiatry and Behavioral Medicine, Medical
College of Wisconsin, Milwaukee, WI (CLW); Department of
Psychiatry and Surgery (Transplant), Yale New Haven Hospital,
New Haven, CT (PZ); Department of Psychosomatic Medicine
and Psychotherapy, Paracelsus Medical University, Nuremberg
General Hospital, Nuremberg, Germany (WS). Send correspondence
and reprint requests to Oliver Freudenreich, M.D., MGH Schizophrenia Program, Erich Lindemann Mental Health Center, 25
Staniford Street, Boston, MA 02114; e-mail: ofreudenreich@
partners.org
& 2015 The Academy of Psychosomatic Medicine. Published
by Elsevier Inc. All rights reserved.

Psychosomatics 56:5, September/October 2015

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Updates in Psychosomatic Medicine

INTRODUCTION
The sheer amount of literature published each year in
medicine is overwhelming. Humankinds collective knowledge is growing exponentially, and medical knowledge has
been estimated in 2010 to double every 3.5 years and has
been projected to double every 73 days by the year 2020.1
The area of psychosomatic medicine or consultationliaison psychiatry is no exception, and it has become all but
impossible for practitioners to keep up-to-date on new
developments across their eld rather than just in a very
narrow area of their expertise. Yet, our patients expect us
to remain informed about new developments in medicine
and practice based on current knowledge.
To help practitioners of psychosomatic medicine
keep updated (and to maintain their accreditation) the
Academy of Psychosomatic Medicine (APM) in collaboration with its sister organization the European Association of Psychosomatic Medicine (EAPM) established
a subcommittee of the APM Research and EvidenceBased Practice Committee, to publish annotated quarterly updates in the eld of psychosomatic medicine. This
article introduces the group process used to canvass the
literature; it provides all references selected by the
subcommittee for 2014; and in addition, it further distills
the literature related to psychosomatic medicine to
provide an overview of important developments in 2014.

METHODS
Beginning in 2013, the evidence-based practice subcommittee of the APM, in collaboration with members from
the EAPM, began publishing annotated updates of
important articles on the APM website (in the Education
section) quarterly.2 The quarterly updates are accessible
to anyone and not restricted to the APM members. In
2014, these quarterly updates covered 15 subspecialties or
sections of psychosomatic medicine. Each quarterly
update contained up to 3 articles per subspecialty area
that were published during that quarter (Epub ahead of
print or published in the journal) and were selected by a
designated section expert from the APM or the EAPM
who volunteered to participate in this educational
endeavor in his or her area of expertise. In addition to
the PubMed article abstract, section experts annotated
the articles using a structured format (Table 1).
For many subspecialty areas, although 1 expert
author was the designated point person and primary
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contributing expert, 2 or more authors were responsible for canvassing the literature in their assigned
topic area and selecting articles of importance; in
addition, the primary experts were encouraged to use
outside consultants (i.e., colleagues with relevant
expertise) and APM special interest groups for article
suggestions. Experts were instructed to preferentially
select high-quality articles. Consistent with the grading scheme for the critical appraisal of literature that
was developed by the Oxford Centre for Evidencebased Medicine, we operationalized high-quality
articles as those that used a randomized controlled
trial design, represented a cohort study, or reported a
meta-analysis.3 Table 2 summarizes the selection
criteria for other types of articles that experts could
include in their updates because of high educational
value.
Authors were instructed to limit themselves to 3
articles per quarter to avoid an uncritical inclusion of
articles; if no articles were deemed high quality or
educationally valuable, none were selected for the
quarter. For this 2014 update in psychosomatic
medicine, 2 authors (O. F. and T. A. S.) created a
consensus list of articles that they judged to be of
particular relevance for general practitioners of psychosomatic medicine who want to educate themselves
about major ndings in psychosomatic medicine in
2014. One of the authors (O. F.) is the chairperson of
the subcommittee, who in this function had collected
and read all submitted articles and annotations before
posting on the website; the other author (T. A. S.)
functioned as a neutral judge, as he had not been
involved in the quarterly updates. For the annual
update, articles were given preference if they reported
on innovations, investigated a clinical topic using
high-quality research methodology, represented consensus documents from important medical bodies, or
educated helpfully about an area of psychosomatic
medicine. The number of nal articles was not limited
initially but evolved during the consensus building.
The overall process of selecting articles for the
quarterly and the annual update is depicted in the
Figure.
RESULTS
A total of 88 articles had been selected in 2014 by the
contributing APM/EAPM experts for annotation and
publication on the APM website. The articles were
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Freudenreich et al.

TABLE 1.

Annotation Format for APM Quarterly Updates

The nding
Concise summary of the study
This should include the (one) main nding in the topic expert's
own words
This should include the population studied, the study design
used, and the main outcome variable
Strength and weaknesses
Comments regarding the appropriateness of the study's
methodology
This should include patient selection and measurement issues
such as rating scales used
This should include the study's power and generalizability
Relevance
Background and the larger context of the study that illustrates
why it is important
This should include applicability for psychosomatic medicine
APM Academy of Psychosomatic Medicine.

related to 15 subspecialties: cardiac psychiatry,49

collaborative care/integrated behavioral health,10,11
emergency psychiatry,12,13 HIV psychiatry,1420
neuropsychiatry,2131 pediatric psychosomatic medicine,3236 psychodermatology,3745 psychonephrology,4655 psycho-oncology and palliative care,5664
serious mental illness,6572 somatic symptom disorders,73 suicide,7478 transplant psychiatry,7985 trauma
and critical care psychiatry,86,87 and womens mental
health.11,8891 In addition, 14 articles with substantial
educational value for general practitioners of psychosomatic medicine psychiatry were selected as described
earlier. The full annotations for those articles (as
provided by the original authors, with some editing
for uniformity) are provided later, and their main
ndings are summarized in Table 3.
Cardiac Psychiatry
Depression As a Risk Factor for Poor Prognosis Among
Patients With Acute Coronary Syndrome: Systematic
Review and Recommendations: A Scientic Statement
From the American Heart Association
Lichtman JH, Froelicher ES, Blumenthal JA, Carney
RM, Doering LV, Frasure-Smith N, et al: Circulation
2014; 129:13501369
The Finding: Despite moderate heterogeneity of
individual studies, this comprehensive systematic
Psychosomatics 56:5, September/October 2015

review found clear connections between depression

and adverse outcomes after acute coronary syndrome (ACS). Based on this review and additional
aspects of this association (e.g., a plausible mechanism connecting depression and adverse outcomes),
the committee concluded that depression should be
considered a risk factor for adverse events after
ACS.
Strengths and Weaknesses: The strengths included
a careful and comprehensive systematic review and
consideration of multiple criteria required to reach risk
factor status. The authors also carefully outlined and
discussed sources of heterogeneity. The weaknesses of
the review included incorporation only of articles
written in English, only considering post-ACS outcomes (rather than onset of cardiac illness or other
conditions), and the inherent limitations and heterogeneity of the reviewed studies. Regarding the assignment as a risk factor, an important weakness was that
the authors did not include the criterion that treatment/reduction of the risk factor leads to improved
prognosis (not yet proven) and that it includes only a
very specic condition rather than coronary artery
disease overall.
Relevance: This article may prove controversial
for the reasons listed earlier. However, there is little
doubt that depression is linked with cardiac mortality
after ACS. Although there has not yet been an
adequately powered study proving that treatment of
depression leads to a reduction in mortality, there have
been several studies showing that management of
depression in patients with cardiac disease leads to
improved health-related quality of life and function.
Whether one considers depression a risk factor, it is
clearly important to address in patients post-ACS.

TABLE 2.

Selection Criteria for Articles Included in the APM

Quarterly Updates

High-quality evidence
Randomized, controlled trial
Cohort study
Meta-analysis
Publications in high-impact journals that practitioners should be
aware of
Novel ndings or approaches that might change practice
Summary statements or expert guidelines by large organizations
Articles with high educational value
APM Academy of Psychosomatic Medicine.

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Updates in Psychosomatic Medicine

FIGURE.

APM/EAPM Quarterly and Annual Updates in Psychosomatic Medicine. The 2014 Topic Areas and Article Selection. APM
Academy of Psychosomatic Medicine, EAPM European Association of Psychosomatic Medicine, SSS Somatic Symptom
Disorder, SMI Serious Mental Illness. *APM website (education section, annotated abstracts): http://www.apm.org/library/articles/
index.shtml.

APM and EAPM Members

Psychosomac Medicine
Topic Area Experts

TOPIC
AREAS

Cardiopsychiatry

Neuropsychiatry

Psychonephrology

Transplant psychiatry

Emergency psych

Ped psychosom med

Psychooncology

Trauma

HIV psychiatry

Psychodermatology

Suicide; SSS; SMI

Womens mental health

QUARTERLY
UPDATES
(APM Website*)
ANNUAL
UPDATE
(Psychosomacs)

Q1

Q2

Asymptomatic HIV-Associated Neurocognitive

Impairment Increases Risk for Symptomatic Decline
Grant I, Franklin DR, Jr., Deutsch R, Woods SP,
Vaida F, Ellis RJ, et al: Neurology 2014; 82:2055
2062
The Finding: In this longitudinal cohort study
(the CHARTER cohort), a diagnosis of asymptomatic neurocognitive impairment (ANI) at the
beginning of the study predicted, over a median
follow-up of 45.2 months, progression to problems in
everyday functioning. Combining self-report and
performance-based measure, the presence of ANI
conferred a relative risk (RR) of 3.0 (CI: 2.14.4)
when compared with patients without impairment at
baseline.
Strength and Weaknesses: This is an important
longitudinal study (as opposed to a cross-sectional
www.psychosomaticsjournal.org

Q3

Q4

Updates in
Psychosomac Medicine

HIV Psychiatry

448

Outside Consultants

study) with a sufciently large sample (N 121) of

patients diagnosed as having ANI and 226 diagnosed
as being cognitively intact. The CHARTER cohorts
longitudinal design might be biased toward those
who can commit to participating in a longitudinal
study (i.e., removing people at the extremes of
function: those who work and those who are
impaired).
Relevance: In patients with HIV infection, preserving cognition remains elusive for some, in whom,
despite seemingly effective HIV treatment, functional
impairments from HIV-associated neurocognitive disorder develop. It is a high priority to develop treatment
strategies (either new drugs or optimizing current
regimens for central nervous system protection) for
patients who are labeled as having ANI (most
patients with HIV-associated neurocognitive disorder)
using the Frascati criteria. In this scheme, ANI
indicates measurable cognitive impairment that is
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Freudenreich et al.
TABLE 3.

Updates in Psychosomatic Medicine 2014: 14 Key Findings

Subspecialty
Domain
Cardiac
psychiatry
HIV psychiatry

Reference No.
4

17

18

Neuropsychiatry

23

31

Major Finding/Relevance
The American Heart Association ofcially concluded that depression should be considered
a risk factor for adverse events after an acute coronary syndrome (ACS). Depression in
post-ACS patients is ignored to the detriment of the patient and must be addressed.
An asymptomatic form of HIV-associated neurocognitive disorder termed asymptomatic
neurocognitive impairment (ANI) increases the risk for cognitive decline that becomes
symptomatic. Patients with HIV infection who have ANI have to be identied, and
attempts should be made to protect cognition.
The old standby rst-generation NNRTI antiretroviral agent efavirenz, which is a component of
standard treatment for HIV infection, is associated with an increased risk of suicidality. It
remains yet to be seen if next-generation NNRTIs have a lower risk for neuropsychiatric
complications.
Cognitive decits 6 months after a stroke were common. After a stroke (regardless of location),
serial testing including formal neuropsychologic testing where there is a discrepancy between
subjective complaints and bedside screening is needed.
A simple bedside test of attention (months of year backward) was both sensitive and specic for
delirium in hospitalized (but not in intensive care) patients. Quality initiatives in hospitals
should pay attention to this simple test.

Psychodermatology

39

Psychotropic medications can cause a variety of dermatologic side effects. Consultation

psychiatrists would benet from this review that details reported reactions for all major
medications and has a small section on treatment and prevention.

Psycho-oncology
and palliative
care

60

The investigators failed to recruit to a placebo-controlled trial for depression in patients with
cancer. Given the importance of clinical psychiatric research in medical settings, the experience
of the authors and the discussion are informative for any C-L psychiatrist who works in
academic settings or who considers conducting a clinical trial in a medical setting.
Patients with cancer with major depression had substantially greater improvement in depression
when treated with manualized depression care when compared with usual treatment. This large,
randomized effectiveness trial convincingly showed the power of intensive and integrated
collaborative care to address depression in patients with cancer. Such coordinated and
interdisciplinary treatment sets the standard for care.

63

Serious mental
illness

68

Patients with serious mental illness admitted for diabetes had an increased risk for (a costly) early
rehospitalization. This nding points to need for better coordinated and integrated medicalpsychiatry care for patients with serious mental illness and diabetes.

Suicide

75

A 41-year longitudinal study established traumatic brain injury as a risk factor for suicide (and
also for other violent deaths). This is an important clinical nding that clinicians should keep in
mind when assessing post-TBI patients, be it returning veterans, people with sports-related head
injuries, or other groups where head injuries are likely (e.g., patients who are homeless).
The US Preventive Services Task Force concluded that there was no clear evidence for benet
from routinely screening asymptomatic primary care patients for suicide risk. This is an
important reminder that indiscriminant, broad screening (in this case for suicidality) can lead to
wasted resources with little to show for it.

76

Transplant
psychiatry

80

In this prospective study, cognitive decline developed in patients after liver transplantation even
though hepatic encephalopathy resolved after transplantation. Not all cognitive dysfunction
seen in patients after liver transplantation is thus explained by hepatic encephalopathy.

Trauma and
critical care
psychiatry

86

This randomized trial found ramelteon to be an effective prevention of delirium in hospitalized

patients. Replication is needed before ramelteon can become standard delirium prophylaxis.
Whether ramelteon is safer and more effective than melatonin in this setting is also unknown.

Women's mental
health

90

In this cohort study, antidepressants were not associated with an increased risk for cardiac
malformations once cofounders (e.g., depression severity) were taken into account. This study
adds to the large body of literature suggesting that either antidepressants are not teratogenic or
the absolute risk is very low.

C-L consultation liaison; NNRTI nonnucleoside reverse transcriptase inhibitors; traumatic brain injury.

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Updates in Psychosomatic Medicine

clinically silent and has no functional relevance. There
is still value in diagnosing ANI: Asymptomatic
might not sound alarming but, as shown in the study, it
is a risk factor for cognitive deterioration, and those
patients need to be identied even when they are
asymptomatic.
Association Between Efavirenz as Initial Therapy for
HIV-1 Infection and Increased Risk for Suicidal
Ideation or Attempted or Completed Suicide: An
Analysis of Trial Data
Mollan KR, Smurzynski M, Eron JJ, Daar ES,
Campbell TB, Sax PE, et al: Ann Intern Med 2014;
161:110
The Finding: Using data from 4 AIDS Clinical
Trials Group studies of treatment-naive patients with
HIV infection who were started with treatment on
randomized antiretroviral treatment regimens, it was
found that the risk of suicidality (dened as suicidal
ideation or attempted or completed suicide) was twice
as high for patients randomly assigned to an efavirenzcontaining regimen when compared with those
assigned to efavirenz-free regimens. Of the observed
9 suicides, 8 were in the efavirenz group.
Strength and Weaknesses: This is the rst analysis
using data about suicidality from random assignment
to treatment regimens with or without efavirenz. Still,
3 of the 4 trials were open label; with suicide already
listed in the prescribing information as a complication,
reporting bias is possible. In addition, suicidality was
not assessed with a standard rating scale, and patients
who were deemed to be at a higher risk for suicidality
might not have been referred to these 4 trials to begin
with. Finally, efavirenz was not compared with
regimens containing other nonnucleoside reverse
transcriptase inhibitors or integrase inhibitors.
Relevance: The nonnucleoside reverse transcriptase inhibitors efavirenz (Sustiva) has been an important cornerstone medication for the treatment of
HIV/AIDS because of its excellent antiretroviral
efcacy. It is also included in the most widely used
single-pill regimen (Atripla). However, its use has
always been complicated by a higher rate of neuropsychiatric side effects and by anecdotal observations
of serious events (such as thoughts of suicide). This
analysis, using data from randomized trials, provides
the best evidence yet that these clinical observations
are true and that there is some risk of suicidal
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thinking (and death from suicide) owing to use of

efavirenz. Thus, careful clinical monitoring for psychiatric problems is needed for patients starting with
the treatment with efavirenz. It remains yet to be seen
if next-generation nonnucleoside reverse transcriptase inhibitorss have a lower risk for neuropsychiatric
complications.
Neuropsychiatry
The Cognitive Burden of Stroke Emerges Even With an
Intact National Institutes of Health Stroke Scale Score:
A Cohort Study
Kauranen T, Laari S, Turunen K, Mustanoja S,
Baumann P, Poutiainen E: J Neurol Neurosurg
Psychiatry 2014; 85:295299
The Finding: Cognitive decits at 6 months after
stroke (without regard for localization) were common
in a working-age cohort. Further, a screening instrument used at the time of discharge was of limited use in
predicting this.
Strengths and Weaknesses: Strict denitions for
cognitive impairment were used; along with the
relatively young sample, this makes the studys ndings striking. However, the baseline cognitive status of
the patients was unknown, and although presumed to
be buoyed by age, relative youth plus stroke suggests
unfavorable CNS vasculopathy burden; thus, mitigating assumptions about baseline cognition.
Relevance: This study highlights the need for
serial cognitive screening in persons with acute,
subacute, and remote stroke. The importance of
formal neuropsychologic testing when subjective
functioning and bedside screening are incongruent
is suggested.
Attention! A Good Bedside Test for Delirium?
ORegan NA, Ryan DJ, Boland E, Connolly W,
McGlade C, Leonard M, et al: J Neurol Neurosurg
Psychiatry 2014; 85:11221131
The Finding: Simple attention screening (months
of year backward) is a sensitive and surprisingly
specic detector of delirium in hospitalized (nonintensive care) populations. It is enhanced by combining it with screens for subjective confusion or a
visuospatial attention task or both.
Strengths and Weaknesses: This article highlighted
the continued problems that exist in delirium detection
Psychosomatics 56:5, September/October 2015

Freudenreich et al.
in the general hospital setting, reviewed proposed
remedies, and made a convincing argument for a
much simpler solution than has been proffered previously. The study design was ambitious (all assessments of the 4200 patients took place on the same
day; this included screening followed by a second
screening with the Confusion Assessment Method,
followed by psychiatric assessment) but it appears to
have been carried out rigorously. The authors did an
excellent job of identifying the potential limiting
factors of the study. The biggest quibble is that
attention is far from a specic delirium nding and
probably ought not be taken as such in a crosssectional assessment. However, as noted by the
authors, very, very few patients with documented
dementia in this study did not have delirium. The fact
that patients with cognitive impairment were more
susceptible to delirium may have mitigated the usual
insensitivity of attention impairment as a diagnostic
screen. In addition, technically, months of the year
backward is not a pure test of attention, as it uses
working memory as well.
Relevance: Delirium detection in the general
hospital remains poor and is often thought to require
signicant investment in time and effort. This article
may have quality improvement implications as it
offers a straightforward and brief bedside method of
detecting delirium.
Psychodermatology
Dermatologic Side Effects of Psychotropic
Medications
Mitkov MV, Trowbridge RM, Lockshin BN,
Caplan JP: Psychosomatics 2014; 55:120
The Finding: The authors presented a broad
overview of the most common dermatologic side
effects associated with psychotropic medications. In
general, dermatologic symptoms are most commonly
associated with antiepileptic medications; the most
serious dermatologic adverse effects are also due to
this class of medications. The authors described the
most common dermatologic conditions, their onset
and clinical course, risk factors for cutaneous drug
reactions, as well as recommendations on how to
diagnose these problems.
Strengths and Weaknesses: The primary strength
of this article was that it presented a comprehensive
Psychosomatics 56:5, September/October 2015

overview of the most common dermatologic side

effects of psychotropic medication and served as good
resource for psychiatrists for information and guidance on recognition, diagnosis, and evaluation of these
conditions. A weakness was that a signicant amount
of the data on cutaneous drug reactions and psychotropic medications were based on case reports or
retrospective data, which limited the quality of the
evidence.
Relevance: Dermatologic side effects are not
uncommonly associated with psychotropic medications, and it is important for practitioners of psychosomatic medicine to be aware of the potential for
dermatologic adverse effects, particularly with certain
medications (i.e., mood stabilizers) and in higher risk
groups. Risk mitigation is already possible for some
medications (e.g., HLA genotyping before carbamazepine use).
Psycho-Oncology and Palliative Care
Conducting an Antidepressant Clinical Trial in
Oncology: Challenges and Strategies to Address Them
Park EM, Raddin RS, Nelson KM, Hamer RM,
Mayer DK, Bernard SA, et al: Gen Hosp Psychiatry
2014; 36:474476
The Finding: The researchers planned a 4-arm
clinical trial to compare the efcacy of citalopram with
placebo and mirtazapine with placebo for depressed
patients with cancer (participants were to be stratied
according to their symptom prole). They were unable
to recruit any participants and, after removing the
placebo arms, were still unable to recruit sufcient
numbers. They described the reasons for poor recruitment (summarized in 4 categories: diagnostic ambiguity, participant recruitment and retention, practical
barriers, and placebo concerns) and the possible
solutions.
Strengths and Weaknesses: This articles strength
was that it was one of only a few that described the
practical aspects of conducting a real clinical research
study in psycho-oncology. Its weakness was that the
researchers were not able to put their potential
solutions to the test.
Relevance: This description of the challenges
of doing clinical research in psychiatry in a medical setting is relevant to all consultation-liaison
psychiatrists.
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Integrated Collaborative Care for Comorbid Major
Depression in Patients With Cancer (SMaRT
Oncology-2): A Multicentre Randomised Controlled
Effectiveness Trial
Sharpe M, Walker J, Holm Hansen C, Martin P,
Symeonides S, Gourley C, et al: Lancet 2014;
384:10991108
The Finding: An integrated, systematic, multicomponent collaborative carebased treatment program for major depression was signicantly better
than usual care in achieving a treatment response in
patients with cancer. The treatment program was
relatively inexpensive.
Strengths and Weaknesses: The strengths of this
trial included its rigorous methods, recruitment by
screening, and high follow-up rate. The main weakness was that, as is usually the case with such trials, the
participants could not be masked to intervention
allocation.
Relevance: The ndings suggested that systematic
and intensive integrated collaborative care treatment
programs could achieve striking results for patients
with comorbid depression.

between 2010 and 2011 with any discharge diagnosis

indicating diabetes mellitus. The study sample was
representative of patients in Washington State with
diabetes, as data were obtained from all community
hospitals in the state. The study limitations were
related to the use of administrative data. First, there
may have been misclassication of patients with
serious mental illness disorders, resulting in their
inclusion in the reference group. Moreover, the
administrative data set used for these analyses did
not include information about health behaviors (such
as smoking, sedentary lifestyle, and poor diet) or
laboratory or pharmacy dataso the effect of these
important factors could not be evaluated.
Relevance: These ndings may indicate poor
quality of medical care for patients with diabetes
who also have comorbid serious mental illness, or
maybe further evidence that patients with serious
mental illness interact with the health care system
differently, and have unique barriers to adherence with
medical care and follow-up. Improving the coordination or integration of outpatient medical and psychiatric care for these complex patients may decrease the
risk of early rehospitalizations.

Serious Mental Illness

The Effect of Serious Mental Illness on the Risk of
Rehospitalization Among Patients With Diabetes
Chwastiak LA, Davydow DS, McKibbin CL, Schur
E, Burley M, McDonell MG, et al: Psychosomatics
2014; 55:134143
The Finding: Among Medicare beneciaries, rehospitalization within 30 days of discharge occurs in
almost 20% of patients, costing the health care system
an estimated $17.4 billion. A key component of the
comprehensive strategy of the Centers for Medicare
and Medicaid Services to reduce costs focuses on
reducing 30-day rehospitalizations for heart failure,
acute myocardial infarction, and pneumonia. In this
study, of all admissions to community hospitals in
Washington State for diabetes between 2010 and 2011,
a diagnosis of serious mental illness was independently
associated with an increased risk of early medical
rehospitalization.
Strength and Weaknesses: This observational
cohort study comprised a very large (82,060 adults
in Washington State), population-based sample of
patients who had a medical-surgical hospitalization
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Suicide
Suicide, Fatal Injuries, and Other Causes of Premature
Mortality in Patients With Traumatic Brain Injury: A
41-Year Swedish Population Study
Fazel S, Wolf A, Pillas D, Lichtenstein P, Langstrom N:
JAMA Psychiatry 2014; 71:326333
The Finding: Drawing on an extended longitudinal
follow-up (4 to 440 y) of more than 218,000 Swedish
individuals who had a traumatic brain injury (TBI),
this study showed that people who survived 6 months
or more beyond a TBI were 3 times more likely to die
prematurely of suicide, assault, or other injuries. Of
particular interest to psychiatrists, post-TBI patients
were twice as likely to die of suicide as compared with
their uninjured siblings.
Strengths and Weaknesses: This study relied on
impressive numbers and on extensive longitudinal
data, taking advantage of comprehensive nationwide
population-based registers in Sweden that also
allowed for comparison with general population
controls and a substantial number (4237,000) of
uninjured siblings; this extensive database enabled
Psychosomatics 56:5, September/October 2015

Freudenreich et al.
uncommon statistical power to examine relatively
infrequent events. Unfortunately, the study was not
able to either specify the type of TBI or quantify the
severity of the TBI.
Relevance: This study underscored the utility of
regarding post-TBI patients as having chronic medical
problems that deserve ongoing attention, perhaps
particularly those who are also prone to impulsivity,
risk-taking behaviors, or substance abuse. Returning
veterans, youth involved in contact sports, and individuals who live in environments where assaults were
more common comprised a population that was at an
increased risk of having a TBI and may invite
psychiatric attention when they pursue medical
attention.
Screening for Suicide Risk in Adolescents, Adults, and
Older Adults in Primary Care: U.S. Preventive Services
Task Force Recommendation Statement
LeFevre ML: Ann Intern Med 2014; 160:719726
The Finding: Although the United States Preventive Services Task Force recommended that primary
care clinicians should remain attentive to screening
patients in high-risk groups (such as immediately
following dismissal from an emergency department
visit for a suicidal act or following a psychiatric
hospitalization), there was insufcient evidence of
benet to support routine screening for suicide risk
in primary care. The American Academy of Family
Physicians and the Canadian Task Force on Preventive Health Care reached similar conclusions. The
United States Preventive Services Task Force continues to support screening for depression in primary
care, provided such screening is coupled with adequate
resources to ensure accurate diagnosis, treatment, and
follow-up. However, the United States Preventive
Services Task Force concluded that there was no clear
evidence that screening for suicide risk in asymptomatic primary care patients yielded improved health
outcomes.
Strengths and Weaknesses: Given that suicide was
the 10th leading cause of death in the United States in
2010, this update of the 2004 United States Preventive
Services Task Force recommendations is timely.
Unfortunately, available studies for review were
sparse, the accuracy of the screening instruments used
varied widely, and no 2 studies used the same
instrument.
Psychosomatics 56:5, September/October 2015

Relevance: Recent emphases on patient safety and

the recognition of the potential adverse effects of
depression in select groups of medical and surgical
patients have increased the attention given to suicide
screening in and out of the hospital. Awareness of the
paucity of evidence for benet from routine screening
for suicide risk in primary care patients may enable
consultation psychiatrists to inform these efforts, such
that the energy and work invested are directed toward
high-risk individuals where intervention may favorably inuence outcome.
Transplant Psychiatry
New-Onset Cognitive Dysfunction Impairs the Quality
of Life in Patients After Liver Transplantation
Tryc AB, Pugrad H, Goldbecker A, Barg-Hock H,
Strassburg CP, Hecker H, et al: Liver Transpl 2014;
20:807814
The Finding: A total of 50 patients were investigated prospectively before orthotopic liver transplantation (OLT), at 6 months, and at 12 months
after OLT. A battery of psychometric tests was used:
the psychometric hepatic encephalopathy score, the
inhibitory control test, the critical icker frequency,
and the Repeatable Battery for the Assessment of
Neuropsychological Status. The hepatic encephalopathy group performed signicantly worse on all
tests in comparison with the nonhepatic encephalopathy group before OLT (psychometric hepatic
encephalopathy score, p o 0.01; inhibitory control
test, p o 0.04; and critical icker frequency, p o
0.01). At 6 months after OLT, the hepatic encephalopathy group still had lower mean scores for critical
icker frequency (p o 0.04) and psychometric
hepatic encephalopathy score (p o 0.09) in comparison with the nonhepatic encephalopathy group. Over
time, the patients in the hepatic encephalopathy
group improved on the Repeatable Battery for the
Assessment of Neuropsychological Status (T1 vs
T3, p o 0.06), whereas a cognitive decline was
measured with Repeatable Battery for the Assessment of Neuropsychological Status for the nonhepatic encephalopathy group (T1 vs T2, p o 0.02,
and T1 vs T3, p o 0.02). At 12 months after OLT, no
signicant differences between the groups were
detectable. Approximately 70% of the patients
showed a decline in cognition, exceeding 10% in
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Updates in Psychosomatic Medicine

at least one cognitive domain. Hepatic encephalopathyrelated cognitive dysfunction was mostly
resolved within the rst 6 months after OLT, and
no patient was diagnosed with minimal hepatic
encephalopathy according to psychometric hepatic
encephalopathy score and inhibitory control test
targets 12 months after OLT.
Strength and Weaknesses: The strengths of the
study involved its prospective design, extensive cognitive
battery, and length of follow-up (12 mo). All patients
received a standard triple-immunosuppression regimen
after OLT, which took away 1 possible confounding
factor. The main limitation of the study was its lack of
information about the possible causes of cognitive
decline posttransplantation.
Relevance: This study addressed the important
topic of cognitive impairment after liver transplantation. Patients with liver transplant often have cognitive
impairment related to hepatic encephalopathy while
on the transplant waiting list; however, they often have
signicant risk factors for other cognitive disorders:
long history of alcohol abuse, cardiovascular disease,
medications, and age. Differentiating reversible from
progressive cognitive decline before and after liver
transplantation is often extremely difcult. This study
brings valuable information regarding the evolution of
the hepatic encephalopathy after liver transplantation
and raises attention to the cognitive decline posttransplantation, which is not related to hepatic encephalopathy. The ndings of the study suggested that 1 year
after OLT, cognitive dysfunctions should not be
interpreted as residual symptoms but instead be
viewed as new-onset cognitive disturbances.

a lower incidence of delirium (p 0.01; odds ratio

0.07 [95% CI: 0.0080.54].
Strength and Weaknesses: The primary strength of
this study was its randomized, placebo-controlled design.
Despite a relatively low number of patients in the trial,
both the groups were reasonably similar concerning risk
factors for development of delirium. The limitations of the
study included that this was not a double-blind study but
was rater-blinded. In addition, although the number of
patients enrolled was more than that needed for power
analysis, the study had a relatively small sample size.
Other weaknesses include the exclusion of patients with
hepatic dysfunction, diagnoses of mood disorders (including bipolar mood disorder and depression), and those with
psychotic disorders. These groups represented not only
those patients who often have sleep/wake dysfunction and
circadian rhythm disturbances but also those who have
also been shown to be at a higher risk for the development
of delirium in the intensive care unit setting; their exclusion
from the study deviates from real clinical practice.
Relevance: During the last several years, varying
strategies regarding delirium prevention, particularly in
intensive care unit patients, have been studied, including
use of dopamine antagonists, cholinesterase inhibitors,
and even benzodiazepines, all with varying results. This
particular study, despite its limitations, was one that is
the rst to show a signicant prophylactic effect on the
incidence of delirium in elderly intensive care unit
patients with the use of the melatonin analogue ramelteon. Interestingly, no published studies exist to show if
ramelteon is more effective (or if more safe) than
melatonin is in clinical trials with human subjects.
Womens Mental Health

Trauma and Critical Care Psychiatry

Preventative Effects of Ramelteon on Delirium: A
Randomized Placebo-Controlled Trial
Hatta K, Kishi Y, Wada K, Takeuchi T, Odawara T,
Usui C, et al: JAMA Psychiatry 2014; 71:397403
The Finding: In a randomized rater-blinded placebo-controlled trial that was conducted in 4 university
hospitals and 1 general hospital involving 67 patients
(24 patients in intensive care units and 43 admitted to
regular acute care wards) between the ages of 65 and
89 years, ramelteon was associated with a lower risk of
delirium (3% vs 32%; p 0.003). After risk factors
were controlled for, ramelteon was still associated with
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Antidepressant Use in Pregnancy and the Risk of

Cardiac Defects
Huybrechts KF, Palmsten K, Avorn J, Cohen LS,
Holmes LB, Franklin JM, et al: N Engl J Med 2014;
370:23972407
The Finding: This cohort study of 64,389 women
nested within a large population-based cohort study of
women enrolled in the nationwide Medicaid Analytic
eXtract found no substantial increase in risk of cardiac
malformations in infants of women with depression
who use antidepressants (selective serotonin reuptake
inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, and tricyclic antidepressants) in the
Psychosomatics 56:5, September/October 2015

Freudenreich et al.
rst trimester when compared with women with
depression without antidepressant use. This association was further attenuated by adjusting for a variety
of factors including severity of depression, other
indications for antidepressant use, sociodemographic
factors, and health care use factors. In the unadjusted
analysis, the RR of any cardiac defect with the use
of a selective serotonin reuptake inhibitor was 1.25
(CI: 1.131.38). However, these ndings were attenuated by adjustment for women with depression only
(RR 1.12, with CI: 1.001.26) and a cohort that was
fully adjusted for depression, depression severity, and
other confounders (RR 1.06; 95% CI: 0.931.22).
Strength and Weaknesses: The strengths of this
study included its large sample size within a national
database of Medicaid enrollees with the ability to link
maternal and infant records as well as the use of
propensity score matching to adjust for a large set of
potential confounders. All major antidepressants were
included. Additionally, this study controlled for the
presence and severity of depression. Although epidemiologic studies have often been challenged by dening exposure and the timing of that exposure during
pregnancy, these investigators enlisted secondary
analyses limiting exposure to the rst trimester and
required women to have a lled prescription or relled
prescription that did not alter the ndings substantially. The ndings were further bolstered by the
replication of prior reports ndings of associations
between well-known risk factors for cardiac malformation, such as diabetes, use of anticonvulsant, and
multifetal pregnancy.
Some of the limitations of this study included its
use of a Medicaid population that is younger and more
racially diverse than populations in prior studies were,
though the authors found no effect related to age or
race. The data also included only live births, thus
excluding pregnancies resulting in stillbirth, termination, or spontaneous abortion that could have been the
result of more severe cardiac malformation. Additionally, the information on important lifestyle factors
(such as smoking, alcohol use, and obesity) was limited
or absent.
Relevance: The use of psychotropics, especially
antidepressants, during pregnancy is still the focus of
much scrutiny. Additionally, the role of untreated or
unremitted symptoms of mental illness on pregnancy
outcomes and infant outcomes has a growing body of
literature. The decision about whether to initiate or
Psychosomatics 56:5, September/October 2015

continue treatment with an antidepressant during

pregnancy should be made with careful consideration that balances the risk of that medication with
the risk of the untreated symptoms, and this study
adds to this discussion by carefully analyzing the
risks of cardiac malformation associated with antidepressants.
This study calls into question previous ndings
from earlier epidemiologic studies that implicated
paroxetine with a higher risk of right ventricular
outow tract obstructions in infants exposed in utero,
which resulted in the Food and Drug Administration
eventually reclassifying the drug to Category D.
Similarly, sertraline, one of the most commonly
prescribed selective serotonin reuptake inhibitors used
in pregnancy, was previously associated with ventricular septal defects. Given the increasing prevalence of
antidepressant use (among other psychotropics) during pregnancy, this study adds to the large body of
literature suggesting low absolute and RR of antidepressant use during pregnancy and specically
argued against teratogenic effects associated with
common antidepressants.
CONCLUSION
A concerted effort by members of the APM and the
EAPM identied important ndings in psychosomatic
medicine that should be of interest for all psychosomatic medicine psychiatrists, even if some content lies
outside the main thrust of the consultative work for
individual practitioners. The group process for canvassing the vast medical literature and creating annotated versions of relevant articles by experts (further
condensed in our list of 14 key ndings for 2014) is one
approach to synthesize medical information. The
utility is 2-fold: one, clinicians and experts alike
remain engaged as students and life-long learners
and two, experts function as peer educators and serve
an important professional function.
The strengths of our selection approach lies in a
group effort by experts to nd the most relevant
articles. Our approach for selecting the quarterly
update articles also had weaknesses. Although the
work group covered many topics in psychosomatic
medicine, not all topics were covered (e.g., gastroenterology and hepatology; chronic pain), and the
selection of only a few articles favors small areas of
psychosomatic medicine (HIV psychiatry) over larger
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Updates in Psychosomatic Medicine

areas (e.g., cardiopsychiatry) that are underrepresented. However, articles were also selected based
on quality, and some areas did not have high-quality
publications this past year and were noncompetitive.
Further, even though key principles of article selection
were outlined, the experts had leeway in making their
ultimate article selections, and some selections may
appear idiosyncratic. Last, limiting the number of
selected articles per quarter to 3 main articles forced
experts to make choices.
In addition, any attempt to further reduce the
number of relevant articles to 14 in this review for the
whole eld would omit some articles that could very
reasonably have been considered. Our nal selection
attempts to provide practitioners of psychosomatic
medicine with articles that capture current trends in
the various subspecialties and practical articles to inform
their clinical practice and help prepare for board
examinations. Still, although our approach is not the
best or only approach, it is a possible approach that uses
a group process and the wisdom of a group of experts to
make lifelong learning possible as a physician. The
APMs approach of eliciting quarterly, annotated
updates from area experts could in principle be adopted
by groups of clinicians (at a hospital or practice or

organization) who come together voluntarily and divvy

up the literature. Without an attempt to synthesize the
literature, individual clinicians would drown in the sea of
information. This group of clinicians plans on continuing
the quarterly updates and make the annual updates a
regular feature in psychosomatics.
Acknowledgment: We would like to thank other
APM and EAPM members who have contributed
articles for consideration but who were not listed as
authors. We particularly want to thank APMs web
person Grace Bachmann who developed the overall
layout for the web-based updates and who carefully
read, edited, and put the abstracts and annotations on
the APM website each quarter.
Disclosure: Oliver Freudenreich has received grant
support from Psychogenics and Forum, has received
honoraria from Global Medical Education and the
MGH Psychiatry Academy, has received consultant
fees from Beacon Health Strategies and Optimal
Medicine, and has received royalties from UpToDate.
Theodore A. Stern is an employee of the Academy of
Psychosomatic Medicine for serving as the editor in
chief of Psychosomatics. The other authors had no
disclosures.

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