Guidelines regarding the treatment of depression during pregnancy were recently published by the American Psychiatric Association and the American College of Obstetricians and Gynecologists. We provide a commentary on these guidelines.
Depression; Pregnancy; Treatment; Guidelines
Palliative care psychiatry is an emerging subspecialty field at the intersection of Palliative Medicine and Psychiatry. The discipline brings expertise in understanding the psychosocial dimensions of human experience to the care of dying patients and support of their families. The goals of this review are (1) to briefly define palliative care and summarize the evidence for its benefits, (2) to describe the roles for psychiatry within palliative care, (3) to review recent advances in the research and practice of palliative care psychiatry, and (4) to delineate some steps ahead as this sub-field continues to develop, in terms of research, education, and systems-based practice.
Palliative care; Hospice; Palliative care psychiatry; Patients; Caregivers; Families; Advance illness; Quality of life; Total pain; Psychotherapy; Dignity therapy; Depression; Delirium; Anxiety; Geriatric disorders
The concepts of healthcare reform and population health are shifting the emphasis from traditional, volume-based care to a model in which value, or quality, predominates. High quality care will be increasingly rewarded, with financial consequences for poor performance. This shift will be accelerated by the use of healthcare technology, a rapidly growing industry with tools ranging from electronic health records to smart phones and web portals. In this article we highlight pertinent legislative reforms followed by a review of technologies that may play a role in the implementation of these reforms. Pediatric Attention Deficit Hyperactivity Disorder is used as an example given the large number of proposed tools for this condition. While the evidence base is weak for some technologies, research regarding web portals is better developed and will be presented as an example of a technology that may allow practitioners and organizations to improve healthcare quality in several dimensions.
Meaningful use; Quality improvement; Healthcare reform; Attention deficit hyperactivity disorder (ADHD); E-health; Digital technology; Electronic health records (EHRs); Remote monitoring systems; Web portals; Videoconferencing; Smart phones; Online therapies; Psychiatry
Neuroimaging, both structural and functional, serve as useful adjuncts to clinical assessment, and can provide objective, reliable means of assessing disease presence and process in the aging population. In the following review we briefly explain current imaging methodologies. Then, we analyze recent developments in developing neuroimaging biomarkers for two highly prevalent disorders in the elderly population- Alzheimer's disease (AD) and late-life depression (LLD). In AD, efforts are focused on early diagnosis through in vivo visualization of disease pathophysiology. In LLD, recent imaging evidence supports the role of white matter ischemic changes in the pathogenesis of depression in the elderly, the “vascular hypothesis.” Finally, we discuss potential roles for neuroimaging biomarkers in geriatric psychiatry in the future.
Geriatric; Psychiatry; Neuroimaging; Biomarkers; Dementia; Alzheimer's disease (AD); Late-life depression (LLD); MRI; DTI; fMRI; PET; FDG-PET; Pittsburgh Compound B (PiB); White matter lesions (WML); Resting-state network; Vascular hypothesis
The current paper presents a novel approach to understanding and treating addiction. Drawing from work in behavioral economics and developments in the new field of neuroeconomics, we describe addiction as pathological patterns of responding resulting from the persistently high valuation of a reinforcer and/or an excessive preference for the immediate consumption of that reinforcer. We further suggest that, as indicated by the competing neurobehavioral decision systems theory, these patterns of pathological choice and consumption result from an imbalance between two distinct neurobehavioral systems. Specifically, pathological patterns of responding result from hyperactivity in the evolutionarily older impulsive system (which values immediate and low-cost reinforcers) and/or hypoactivity in the more recently evolved executive system (which is involved in the valuation of delayed reinforcers). This approach is then used to explain five phenomena that we believe any adequate theory of addiction must address.
Addiction; Treatment; Pathology; Behavioral economics; Neuroeconomics; Neural systems; Theory; Impulsivity; Reinforcer; Executive function; Human
Although concern has been raised about antipsychotic prescribing to youth with attention-deficit/hyperactivity disorder (ADHD), the available database is limited to individual studies. Therefore, in order to provide a synthesis of prevalences and time trends, we conducted a systematic review and pooled analysis of pharmaco-epidemiologic data on antipsychotic use in ADHD youth. Of 1806 hits, 21 studies (N) were retained that reported analyzable data for three separate populations: 1) antipsychotic-treated youth (N=15, n=341,586); 2) ADHD youth (N=9, n=6,192,368), and 3) general population youth (N=5, n=14,284,916). Altogether, 30.5±18.5% of antipsychotic-treated youth had ADHD. In longitudinal studies, this percentage increased over time (1998-2007) from 21.7±7.1% to 27.7±7.7%, ratio=1.3±0.4. Furthermore, 11.5±17.5% of ADHD youth received antipsychotics. In longitudinal studies, this percentage also increased (1998-2006) from 5.5±2.6% to 11.4±6.7%, ratio=2.1±0.6. Finally, 0.12±0.07% of youth in the general population were diagnosed with ADHD and received antipsychotics. Again, in longitudinal studies, this percentage increased over time (1993-2007): 0.13±0.09% to 0.44±0.49%, ratio=3.1±2.2.
Taken together, these data indicate that antipsychotics are used by a clinically relevant and increasing number of youth with ADHD. Reasons for and risk/benefit ratios of this practice with little evidence base require further investigation.
Attention-deficit/hyperactivity disorder; ADHD; Antipsychotics; Prescribing; Trends; Correlates; Pharmacoepidemiology; Psychiatry
NOS1AP is an attractive candidate gene for schizophrenia susceptibility. Linkage and association studies from multiple samples drawn from different populations indicate that a schizophrenia susceptibility gene is located in the region of chromosome 1 containing NOS1AP. Increased expression of NOS1AP is observed in post-mortem samples from individuals with schizophrenia. NOS1AP binds to neuronal nitric oxide synthase and synapsin, other candidate genes for schizophrenia, and may disrupt signal transduction through the NMDA receptor complex, leading to hypofunctioning of that system. In this review I will present the evidence supporting NOS1AP as a schizophrenia susceptibility gene, with a focus on explaining the strengths and weaknesses of the evidence obtained from each type of study that has been conducted.
Following Linehan’s biosocial model, we conceptualize emotion dysregulation in borderline personality disorder (BPD) as consisting of four components: emotion sensitivity, heightened and labile negative affect, a deficit of appropriate regulation strategies, and a surplus of maladaptive regulation strategies. We review the evidence supporting each of these components. Given the complexity of the construct of emotion dysregulation and its involvement in many disorders, there is a need for research that specifies which components of emotion dysregulation are under study and also examines the interplay amongst these emotion dysregulation components.
Borderline personality disorder; BPD; Emotion sensitivity; Biosocial theory; Affective instability; Negative affect; Emotion regulation; Distress tolerance; Emotion dysregulation; Emotion regulation strategies; Inadequate appropriate regulation strategies; Maladaptive regulation strategies; Psychiatry
We review recent gene-environment studies relevant to borderline personality disorder, including those focusing on impulsivity, emotion sensitivity, suicidal behavior, aggression and anger, and the borderline personality phenotype itself. Almost all the studies reviewed suffered from a number of methodological and statistical problems, limiting the conclusions that currently can be drawn. The best evidence to date supports a gene-environment correlation (rGE) model for borderline personality traits and a range of adverse life events, indicating that those at risk for BPD are also at increased risk for exposure to environments that may trigger BPD. We provide suggestions regarding future research on GxE interaction and rGE effects in borderline personality.
Borderline personality disorder; BPD; Psychopathology; Gene-environment interaction; GxE; Gene-environment correlation; rGE; Impulsivity; Emotion sensitivity; Suicidal behavior; Aggression; Anger; Adverse life events; Environmental factors; Personality disorders; Psychiatry
Determining the genetic architecture of liability for complex neuropsychiatric disorders like autism spectrum disorders and schizophrenia poses a tremendous challenge for contemporary biomedical research. Here we discuss how genetic studies first tested, and rejected, the hypothesis that common variants with large effects account for the prevalence of these disorders. We then explore how the discovery of structural variation has contributed to our understanding of the etiology of these disorders. The rise of fast and inexpensive oligonucleotide sequencing and methods of targeted enrichment and their influence on the search for rare genetic variation contributing to complex neuropsychiatric disorders is the next focus of our article. Finally, we consider the technical challenges and future prospects for the use of next-generation sequencing to reveal the complex genetic architecture of complex neuropsychiatric disorders in both research and the clinical settings.
Human genetics; Genomics; Genetic architecture; Complex traits; Next-generation sequencing; Targeted enrichment; Single nucleotide variants; SNVs; Single nucleotide polymorphisms; SNPs; Structural variation; Copy number variants; CNVs; Complex neuropsychiatric disorders; Schizophrenia; Autism; Genetic disorders; Psychiatry
Mild cognitive impairment (MCI) is the intermediate stage between the cognitive changes of normal aging and dementia. Individuals with MCI show cognitive impairment greater than expected for their age, but otherwise are functioning independently and do not meet the criteria for dementia. MCI is important because it constitutes a high risk group for dementia. Ideally, prevention strategies should target individuals who are not even symptomatic. Indeed, the field is now moving towards identification of asymptomatic individuals who have underlying Alzheimer’s disease (AD) pathology that can be detected by using biomarkers and neuroimaging technologies. To this effect, the Alzheimer’s Association and the National Institute on Aging have developed a new classification scheme that has categorized AD into a preclinical phase (research category), MCI due to AD, and dementia of Alzheimer’s type. On the other hand, there are also ongoing researches to understand high risk groups for non-Alzheimer’s dementia as well.
Aging; Mild cognitive impairment; Neuropsychiatric symptoms; Dementia; Dementia of Alzheimer’s type; Cognitive Impairment No dementia; Benign and malignant forgetfulness; Age-associated memory impairment; Age-associated cognitive decline; Mild neurocognitive decline; Age-associated memory impairment; Questionable dementia; Asymptomatic Alzheimer’s disease
The goal of this article is to provide a selective and targeted review of the neuroimaging literature on psychopathic tendencies and antisocial behavior and to explore the extent to which this literature supports recent cognitive neuroscientific models of psychopathy and antisocial behavior. The literature reveals that individuals who present with an increased risk for reactive, but not instrumental, aggression show increased amygdala responses to emotionally evocative stimuli. This is consistent with suggestions that such individuals are primed to respond strongly to an inappropriate extent to threatening or frustrating events. In contrast, individuals with psychopathic tendencies show decreased amygdala and orbitofrontal cortex responses to emotionally provocative stimuli or during emotional learning paradigms. This is consistent with suggestions that such individuals face difficulties with basic forms of emotional learning and decision making.
Amygdala; Orbital frontal cortex; Psychopathy; Instrumental aggression; Reactive aggression
Impairment of cortical circuit function is increasingly believed to be central to the pathophysiology of schizophrenia (Sz). Such impairments are suggested to result in abnormal gamma band oscillatory activity observed in Sz patients, and likely underlie the psychosis and cognitive deficits linked to this disease. Development of improved therapeutic strategies to enhance functional outcome of Sz patients is contingent upon a detailed understanding of the mechanisms behind the cortical circuit development and maintenance. Convergent evidence from both Sz clinical and preclinical studies suggests impaired activity of a particular subclass of interneuron which expresses the calcium binding protein parvalbumin is central to the cortical circuit impairment observed. Here we review our current understanding of the Sz related cortical circuit dysfunction with a particular focus on the role of fast spiking parvalbumin interneurons in both normal cortical circuit activity and in NMDA receptor hypofunction models of the Sz disease state.
Schizophrenia; Gamma oscillations; Interneurons; Parvalbumin; NMDAR; GAD67; Psychiatry
The human gut harbors a complex community of microbes that profoundly influence many aspects of growth and development, including development of the nervous system. Advances in high-throughput DNA sequencing methods have led to rapidly expanding knowledge about this gut microbiome. Here, we review fundamental emerging data on the human gut microbiome, with a focus on potential interactions between the microbiome and autism spectrum disorders (ASD) and consider research on atypical patterns of feeding and nutrition in ASD and how they might interact with the microbiome. Finally we selectively survey results from studies in rodents on the impact of the microbiome on neurobehavioral development. The evidence reviewed here suggests that a deeper understanding of the gut microbiome could open up new avenues of research on ASD, including potential novel treatment strategies.
Gut microbiome; Nervous system; Behavior; Autism; Autism spectrum disorders; ASDs; Feeding; Nutrition; Dietary intake; Animal studies; Neurobehavioral development; Genetic disorders; Psychiatry
The neuroimaging literature of Attention-Deficit/Hyperactivity Disorder (ADHD) is growing rapidly. Here, we provide a critical overview of neuroimaging studies published recently, highlighting perspectives that may be of relevance for clinicians. After a comprehensive search of PubMed, Ovid, Web of Science, and EMBASE, we located 41 pertinent papers published between January 2011 and April 2012, comprising both structural and functional neuroimaging studies. This literature is increasingly contributing to the notion that the pathophysiology of ADHD reflects abnormal interplay among large-scale brain circuits. Moreover, recent studies have begun to illuminate the mechanisms of action of pharmacological treatments. Finally, imaging studies with a developmental perspective are revealing the brain correlates of ADHD over the lifespan, complementing clinical observations on the phenotypic continuity and discontinuity of the disorder. However, despite the increasing potential to eventually inform clinical practice, current imaging studies do not have validated applications in day-to-day clinical practice. Although novel analytical tools will likely accelerate the pace of translational applications, at the present time we caution regarding the inappropriate commercial misuse of imaging techniques in ADHD.
ADHD; neuroscience; neuroimaging; MRI
Children with an autism spectrum disorder have significant impairment in social skills. This area of development has also been the focus of many intervention studies. In this article we review intervention studies published over the past two years. Three topical areas were addressed in current interventions: social skills knowledge, peer relationships, and joint attention/joint engagement. Younger children most often received interventions on joint attention/joint engagement and older, higher functioning children received interventions on social knowledge and peer relationship development. Both single subject research designs and group designs were reviewed. One advancement was that more randomized controlled trials were reported, as well as effectiveness trials in the community. Study quality was also rated. More group than single subject designs were rated as adequate or strong in quality. Overall, moderate to large effects were found for interventions targeting joint attention/joint engagement and peer relationships with mixed effects on interventions targeting social skills knowledge. Future studies should focus on isolating the active ingredients of interventions and include broader participant representation.
Interventions; Social impairment; Autism; Autism spectrum disorder; Social skills; Randomized controlled trials; Single subject research designs; Joint attention; Joint engagement; Peer relationships; Social knowledge; Psychiatry
There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care.
Bipolar disorder; Mood disorder; Co-occurring conditions; Primary care; Integrated care; Collaborative care; Chronic Care Model; CCM; Screening; Diagnosis; Treatment; Access; Mental health services; Psychiatry
Although an increasing number of individuals with autism spectrum disorders are entering adulthood, currently there are few evidence-based programs for individuals later in the life course. In this paper we present an overview of recent research on outcomes for adolescents and adults with ASD and highlight the role of the family for individuals with ASD during the transition to adulthood. We also discuss multi-family group psychoeducation as a promising model for use with individuals with ASD transitioning to adulthood.
Autism; Autism spectrum disorders; ASD; Adolescence; Adulthood; Transition; Psychoeducation; Family; Intervention; Outcomes; Psychiatry
Major Depressive Disorder is a serious medical illness which is responsible for considerable morbidity and disability. Despite decades of research, the neural basis for depression is still incompletely understood. In this review, evidence from neuroimaging, neuropsychiatric and brain stimulations studies are explored to answer the question regarding the localization of depression in the brain. Neuroimaging studies indicate that although many regions of the brain have been repeatedly implicated in the pathophysiology of depression, not many consistent findings have been found until present. In recent times, the focus of neuroimaging has shifted from regional brain abnormalities to circuit level connectivity abnormalities. However, connectivity models are inherently more complicated, and the validity of these models remains to be tested. Neuropsychiatric studies of illnesses such as Parkinson’s Disease and stroke provide promising clues regarding areas involved in depression, but again consistent findings are rare. Similarly, stimulation of a variety of brain regions and circuits has been reported as being effective in depression. Therefore, the current knowledge indicates that the pathophysiology of depression may be distributed across many brain regions and circuits. In future studies, this distributed nature of depression needs to be further investigated, primary and secondary areas affected need to be identified, and new paradigms to explain complex mental functions need to be explored.
Depression; Major depressive disorder; MDD; Unipolar depression; Limbic system; Resting state connectivity; Neuroimaging; fMRI; MRI; PET; Parkinson’s disease; Stroke; Deep brain stimulation; DBS; Transcranial magnetic stimulation; TMS; Vagus nerve stimulation; VNS; Mood disorders; Psychiatry
Every year, suicide is among the top 20 leading causes of death globally for all ages. Unfortunately, suicide is difficult to prevent, in large part because the prevalence of risk factors is high among the general population. In this review, clinical and psychological risk factors are examined and methods for suicide prevention are discussed. Prevention strategies found to be effective in suicide prevention include means restriction, responsible media coverage, and general public education, as well identification methods such as screening, gatekeeper training, and primary care physician education. Although the treatment for preventing suicide is difficult, follow-up that includes pharmacotherapy, psychotherapy, or both may be useful. However, prevention methods cannot be restricted to the individual. Community, social, and policy interventions will also be essential.
Suicide; Risk factors; Diagnostic risk factors; Depressive disorders; Bipolar disorders; Anxiety disorders; Alcohol and other substance abuse; Schizophrenia; Aggression; impulsivity; and hostility; Hopelessness; Heredity; Childhood trauma; Past attempts; Prevention; Means restriction; Media coverage; Identification methods; Diagnosis; Treatment; Psychotherapy; Pharmacotherapy; Electroconvulsive therapy; Mood disorders; Psychiatry
Major depression; Mood disorders; Alcoholism; Suicide; Antidepressants; Psychiatry
Major depression represents one of the most disabling illnesses and current treatments are only partially effective. All antidepressant agents modulate the monoamine system, which likely accounts for the similar efficacy profile of available treatments. Herein we will summarize the current state of depression therapeutics and assess the antidepressant development pipeline. Antidepressant response rates in controlled trials are estimated at ~54% and real-world effectiveness data suggests a somewhat lower rate. Response rates are lower still in patients who have not responded to previous treatment attempts and meaningful advancements will likely come only from identification of mechanistically novel agents. Monoaminergic agents largely dominate the antidepressant development pipeline, however the glutamate neurotransmitter system represents a bright spot on the antidepressant horizon. We review in detail findings regarding the antidepressant effects of the glutamate N-methyl-d-aspartate receptor antagonist ketamine in order to highlight the promise of novel agents as future treatments for major depression.
Major depressive disorder; MDD; Treatment-resistant depression; TRD; Antidepressant; Drug discovery; Psychopharmacology; Glutamate; Ketamine; N-methyl-d-aspartate receptor; NMDAR; Mood disorders; Psychiatry
Alcohol use disorders (AUDs) and depressive illnesses are highly prevalent, frequently co-occur, and are associated with worse outcomes when paired. The assessment and treatment of patients with co-occurring alcohol use disorders and depressive illnesses is wrought with many significant challenges. When it comes to advocating treatment guidelines for this dually diagnosed population, the data are limited, but nonetheless do suggest that an integrated approach to patients presenting with co-occurring AUD and depressive symptoms can be efficacious. In this approach, ongoing evaluation and treatment are provided under one roof according to the evolving needs of each patient. Utilizing antidepressant medications in conjunction with psychosocial therapies may augment overall treatment efficacy; data also suggest that combining and tailoring psychosocial therapies such as motivational enhancement therapies, cognitive therapies, and twelve-step facilitation may further improve treatment outcomes for patients with co-occurring depressive and alcohol use disorders.
Depression; Mood disorders; Substance use disorder; SUD; Alcohol; Alcoholism; Alcohol use disorder; AUD; Dual diagnosis; Assessment; Treatment; Outcomes; Pharmacotherapies; Antidepressants; Psychosocial therapies; Motivational enhancement therapy; Cognitive behavioral therapy; Relapse prevention therapy; Contingency management; Twelve-step facilitation
Bipolar disorder and alcohol use disorder represent a significant comorbid population, which is significantly worse than either diagnosis alone in presentation, duration, co-morbidity, cost, suicide rate, and poor response to treatment. They share some common characteristics in relation to genetic background, neuroimaging findings, and some biochemical findings. They can be treated with separate care, or ideally some form of integrated care. There are a number of pharmacotherapy trials, and psychotherapy trials that can aid programme development. Post-treatment prognosis can be influenced by a number of factors including early abstinence, baseline low anxiety, engagement with an aftercare programme and female gender. The future development of novel therapies relies upon increased psychiatric and medical awareness of the co-morbidity, and further research into novel therapies for the comorbid group.
Alcohol Use Disorder; Bipolar Disorder; treatment; integrated; psychotherapy; pharmacotherapy; genetic; neuroimaging; comorbidity; treatment programme; FIRESIDE; integrated group therapy
The diagnosis of bipolar affective disorder (BD) is often delayed, and preceded by incorrect diagnoses and potentially harmful treatment, and the development of the disorder is associated with suicidal behavior and help-seeking. A number of clinical features have been linked to an increased risk of going on to develop BD, in particular attenuated symptoms of BD, personality traits such as cyclothymia, and general psychopathological symptoms. A number of these show high specificity, indicating that it may be possible to target detection and intervention on people at high risk of BD, and hopefully moderate the course of the illness and improve treatment outcome. This article summarises recent evidence on the characteristics of the prodrome to BD and discusses the potential value and challenges of early detection and intervention in BD.
Bipolar affective disorder; at risk; high risk; prodrome; early intervention; early detection; mania; hypomania; depression; prevention; secondary disability