The biopsychosocial model is the conceptual status quo of contemporary psychiatry. Although it has played an important role in combatting psychiatric dogmatism, it has devolved into mere eclecticism. ...Other non-reductionistic approaches to medicine and psychiatry such as William Osler's medical humanism or Karl Jaspers' method-based psychiatry should be reconsidered.
Objective
Drugs can be divided into two major categories, symptomatic and disease modifying. This review explores whether and how psychiatric drugs fall into one or the other of those categories, and ...the implications of those results for clinical practice and research in psychopharmacology.
Method
Narrative review.
Results
Most psychiatric drugs have only short‐term effects of improving active symptoms. They do not show long‐term benefits for the underlying disease, such as improving the course of illness and improving mortality. Evidence is provided for this claim in the treatment literature of antidepressants for depressive illness and antipsychotics for schizophrenia. Developing truly beneficial drugs for disease modification also is limited by the poor clinical and biological validity of Diagnostic and Statistical Manual diagnoses as well as the use of invalid falsely positive maintenance efficacy randomized discontinuation trial designs.
Conclusions
Current psychopharmacology is limited mostly to symptomatic effects, not transformative treatments for the diseases underlying those symptoms. A change in approach is needed in psychopharmacology practice and research, focusing on long‐term disease modification rather than short‐term symptom improvement.
Objective
In the past decade, since the innovation of the smartphone, there has been an increase in depression, anxiety, and suicidality among teenagers and young adults. The objective of this ...article was to review the current evidence for these associations and to provide initial clinical guidance.
Methods
A narrative review of the available literature on digital technology, social media, and psychiatric outcomes in adolescents.
Results
Psychiatric outcomes have worsened in adolescents in the past decade, correlating with the invention of the smartphone and the rise of social media. Depressive symptoms among American teenagers rose rapidly around 2012 and now are reported in 22% of adolescents, which is at least double the rate in adults. Suicide rates have risen, especially among teenage girls in the United States, in whom there has been a doubling of completed suicide in the past decade. A causal relationship between social media use and these harmful psychiatric outcomes is supported by emerging randomized data showing reduced depressive symptoms associated with a decrease in social media use in college students.
Conclusions
Social media and digital technology correlate with harmful psychiatric outcomes in adolescents and young adults. Clinical recommendations should include limitations in social media use.
-Patient Health Questionnaire 9 (PHQ-9) has been widely validated for depression screening in primary care in high- and low-income countries.-A two-stage screening is recommended for depression.-A ...Mental Health Professional (MHP) should confirm the diagnosis by use of a semi-structured diagnostic interview.
Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care setting.
We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.
Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 – 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.
Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our results.
PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.
William Osler (1849-1919) is often considered the most influential physician in the emergence of science-based medicine. However, his approach to clinical medicine tends to be misunderstood, and its ...relevance to psychiatry has not been explored systematically. Osler's approach to the patient had four components: biological reductionism about disease, a scientific approach to clinical diagnosis, therapeutic conservatism, and a humanistic approach to the person. These concepts conflict with the pragmatic, eclectic, anti-reductionistic assumptions of contemporary psychiatry, as codified in its interpretation of a "biopsychosocial" model. This model leads to unscientific practice, with excessive use of medications given for symptoms, and inattention to identifying and treating diseases. This article suggests that implementing Osler's philosophy of medicine in psychiatry would greatly benefit the latter. It would inaugurate a new "biohumanistic" approach to psychiatry.
The DSM system has never acknowledged a central position for mixed states; thus, mixed depressions have been almost completely neglected for decades. Now, DSM-5 is proposing diagnostic criteria for ...depression with mixed features that will lead to more misdiagnosis and inadequate treatment of this syndrome. Different criteria, based on empirically stronger evidence than exists for the DSM-5 criteria, should be adopted.
Adult attention-deficit disorder (ADD) is a common diagnosis, and amphetamine medications are increasingly used. Recent reports suggest high prevalence of affective temperaments, such as cyclothymia, ...in adult ADD. This study reexamines prevalence rates as reflecting misdiagnosis and reports for the first time on the effects of amphetamine medications on mood/anxiety and cognition in relation to affective temperaments. Among outpatients treated at the Tufts Medical Center Mood Disorders Program (2008-2017), 87 cases treated with amphetamines were identified, versus 163 non-amphetamine-treated control subjects. Using the Temperament Scale of Memphis, Pisa, Paris and San Diego-Autoquestionnaire, 62% had an affective temperament, most commonly cyclothymia (42%). In amphetamine-treated cases, mood/anxiety symptoms worsened notably in 27% ( vs. 4% in the control group, risk ratio RR 6.2, confidence interval CI, 2.8-13.8), whereas 24% had moderate improvement in cognition ( vs. 6% in the control group; RR, 3.93; CI, 1.9-8.0). Affective temperaments, especially cyclothymia, are present in persons about one-half of persons diagnosed with adult ADD and/or treated with amphetamines.
To reanalyze Aristotle's classic lecture, "On melancholy," with current clinical interpretations.
The full lecture is described and interpreted in a new translation.
Aristotle's lecture has been ...understood to reflect a claim about a link between genius and madness, or more specifically depression and genius. In fact, his concept of melancholia included what today would be called mania, and thus his lecture really is about manic-depressive illness (MDI) and genius. He appears to have been the first ancient thinker (not Aretaeus of Cappadocia) to identify manic and depressive states as part of the same disease. Aristotle claims that MDI is necessary in all persons who become great leaders in politics, thinkers in philosophy, or inspired poets or artists. Specifically, he sees the mood states as producing such genius especially when mild as part of mood temperaments (dysthymia, cyclothymia, hyperthymia in modern terms), but also sometimes in full-blown mood disease. Though he makes his argument in the language of humoral theory about black bile, his clinical insights mostly coincide with contemporary empirical data on creativity and leadership.
Properly understood, Aristotle is making a radical claim about MDI, which would have major implications for understanding leadership in particular, and greatness in general.
The widely held clinical view of ‘antidepressants’ as highly effective and specific for the treatment of all types of depressive disorders is exaggerated. This sobering conclusion is supported by ...recent findings from the NIMH‐sponsored STEP‐BD and STAR*D projects. Antidepressants have limited short‐term efficacy in unipolar depressive disorders and less in acute bipolar depression; their long‐term prophylactic effectiveness in recurrent unipolar major depression remains uncertain, and is doubtful in recurrent bipolar depression. These limitations may, in part, reflect the excessively broad concept of major depression as well as unrealistic expectations of universal efficacy of drugs considered ‘antidepressants.’ Treatment‐refractory depression may reflect failure to distinguish depressive conditions, particularly bipolar disorder, that are inherently less responsive to antidepressants. Antidepressants probably should be avoided in bipolar depression, mixed manic‐depressive states, and in neurotic depression. Expectations of antidepressants for specific types of patients with symptoms of depression or anxiety require critical re‐evaluation. A revival of the concept of neurotic depression would make it possible to identify patients with mild‐to‐moderate, chronic or episodic dysthymia and anxiety who are unlikely to benefit greatly from antidepressants. Diagnostic criteria for a revival of the concept of neurotic depression are proposed.
PDF
