In 1934, the writer James Joyce sought treatment for his severely disturbed daughter, Lucia, and brought her to Dr. Carl Jung for an analysis. (Soon after, Lucia received a diagnosis of 

.) James Joyce saw a direct connection between his own creative genius and his daughter’s illness. “Whatever spark or gift I possess has been transmitted to Lucia,” Joyce told Jung, “and it has kindled a fire in [Lucia’s] brain.”

 But Jung perceived an important distinction between father and daughter. He described them as “two people going to the bottom of a river, one falling and the other diving.”

 I believe Jung was getting at a crucial distinction: that between the 

 nature of psychosis (“falling”) and the 

 act of the creative imagination (“diving”).

All this comes to mind in light of an op-ed by Mark Lukach that recently appeared in the 

 Lukach gives a poignant account of his wife’s multiple episodes of psychosis, which-eerily enough-tend to recur on or about Halloween. Lukach describes his wife’s first psychotic episode as follows:

It came out of nowhere. She got nervous about her new job; she lost her appetite; she stopped sleeping; she began having delusions. The first delusions were encouraging. She said she spoke to God, who told her that she was going to be fine. Giulia had never been very religious, so I was alarmed, but at least she was hearing things that were comforting. But then, the delusions turned on her. The voices said she wasn’t going to make it, there was no point in even trying, she was better off not being here. That’s how she ended up in the hospital the first time. They gave her medication. The delusions eventually went away. She was depressed for a long time afterward. They gave her more medication and then she got better.

When his wife’s second hospitalization for psychosis occurred, Mr. Lukach began to reflect on some supposed connections-or perhaps analogies-between her delusions and the imaginative activities he and his son enjoy. He writes that:

. . . as a parent, I love imagination. I constantly make believe with my son [Jonas], to make the world more exciting and interesting. There’s Fred the Friendly Coyote, whom we sometimes hear at night in the hills nearby; the monster broom in our closet to sweep the scary monsters out of the house. . . Maybe just as the make-believe world is a place of delight and refuge for Jonas, there’s something profound or even helpful in what Giulia envisions. Maybe.

It would be a hard-hearted reader indeed who did not feel sympathy for Mr. Lukach, his wife, and son. And those of us who have dealt with the scourge of mental illness in our families-this writer included-will naturally respond with empathy to Mr. Lukach’s “look on the bright side” re-frame of his wife’s psychosis. But I think there is a serious error in this view of psychosis. As Jung understood in his encounter with Lucia Joyce, there is a world of difference between the voluntary, playful engagement of the imagination, and the involuntary descent into psychosis.

Mr. Lukach’s wife apparently received a diagnosis of bipolar disorder. Re-framing her psychosis as “something profound or even helpful” is an understandable but misguided romanticizing of mental illness. It is a reflection of a larger pattern of rationalization that presents serious mental illness as merely an alternative way of seeing the world-or even as a profoundly creative encounter with the universe. As my colleague, Joseph Pierre, MD, has pointed out in his critique of a report from the British Psychological Society (BPS):

. . . the BPS report goes beyond its well-intended attempt to destigmatize psychosis, treading into the territory of romanticizing it. It talks of the positive aspects of psychosis, the historical reverence of psychotic symptoms in shamanistic cultures, and a potential link between psychosis and 

. Again, that sounds good, but to one experiencing a psychotic disorder, there are few upsides. Psychotic disorders are by definition associated with impairment, not benefits. And sadly, while there is a link between creativity and 

, the creative spark is all too often destroyed among those with schizophrenia.

It is also tempting-even for clinicians-to read “creativity” and artistry into what are essentially psychotic thought processes.4 We see an example of this in the writing of the French dramatist and poet, Antonin Artaud (1896-1948). Artaud suffered from serious psychiatric problems for much of his life and appears to have been frankly psychotic at times.

 In one of his letters, Artaud writes, “My mind is open through the belly and from below it piles up dark, inexpressible knowledge full of subterranean tides, concave blocks and frozen turbulence.”

 Crucially, he then adds, “Do not mistake this for imagery.” I believe Artaud was putting into words his 

 As psychiatrist Dr. Albert Rothenberg has noted:

In a technical sense, direct outpouring of unconscious processes is the sine qua non of schizophrenia because persons suffering from this condition are unable to marshal the defenses and other adaptive forms of mastery which keep these processes under wraps for most of us. If poetry were really the result of a direct outpouring of unconscious processes, schizophrenia and poetic creativity would be equivalent.

Of course, they are far from equivalent. Nor is the psychotic state one of playful and imaginative creativity, of the sort engaged in by Mark Lukach and his son. To be clear: many people with psychotic illnesses can be immensely creative and “imaginative” in the way Mark Lukach describes, sometimes drawing inspiration from their periods of psychosis. But these creative acts usually occur during periods of remission or recovery. As Dr. Rothenberg concludes in his important book on creativity, “. . . full psychological health and lucidity would be optimal for all types of creativity.”

In short, imagination and psychosis are different categories of experience and should not be confused or conflated. Indeed, I believe the most helpful part of Mr. Lukach’s article comes near the end, when he writes: “We hope that psychosis never returns for Giulia. It’s a terrible, disorienting experience, and I’m relieved that we know which medications help her weather that storm.”

This article was posted 11/3/17 and has since been updated.

 Acocella J. A fire in the brain. The difficulties of being James Joyce’s daughter. 

 Lukach M. When the make-believe world is all too real. 

https://www.nytimes.com/2017/10/27/well/family/when-the-make-believe-world-is-all-too-real.html

 Pierre J. Psychosis sucks! Antipsychiatry and the romanticization of mental illness. 

https://www.psychologytoday.com/blog/psych-unseen/201503/psychosis-sucks

. Baltimore, MD: Johns Hopkins University Press; 1985:13-23. 

http://www.newworldencyclopedia.org/entry/Antonin_Artaud

 Artaud A. Further letter about myself. In: Corti V, trans. 

. Vol 1. London, UK: Calder & Boyars; 1968:187.

 Rothenberg A. Psychosis and the creation of poetry. 

https://www.psychologytoday.com/blog/creative-explorations/201610/psychosis-and-the-creation-poetry

 Pies RW. Scientific creativity in psychiatry. 

http://www.psychiatrictimes.com/psychotherapy/scientific-creativity-psychiatry

Articles

Imagination and psychosis are different categories of experience, and should not be confused or conflated. 

Confusing Psychosis with Imagination

The approach that has been used for revising the 

 since its inception has been to overhaul the diagnostic classification in its entirety at fixed intervals. While revising the entire DSM in this way has some advantages, such as ensuring the uniformity and stability of the diagnostic definitions during the interval in which the manual is in effect, a significant disadvantage is that it prevents the incorporation of new scientific knowledge into DSM as it emerges.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way toward the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances. Thus, rather than waiting until the next wholesale revision to implement a clinically useful change (such as incorporating a clinically validated biomarker into the definition of a disorder), such a change could be put into effect as soon as it has been determined that it is diagnostically advantageous to do so. Moreover, implementing a continuous data-driven approach has the added advantage of discouraging changes that are not well supported by empirical evidence.

It is expected that most submissions will originate from interested persons who are external to the APA committee overseeing the DSM revision process (eg, psychiatric researchers, individual clinicians). This is in marked contrast to the way prior DSM revisions were done, during which proposals were drafted by DSM workgroup members who were also responsible for providing supportive literature reviews and data re-analyses.

) was set up by the APA at the beginning of this year to field proposals for changes to DSM-5. Proposals must be accompanied by supportive information including the reasons for the change and, depending on the nature of the proposal, data documenting improvements in validity across a range of validators, evidence of reliability and clinical utility, and a consideration of potential deleterious consequences associated with the proposed change.

This new continuous revision process is being overseen by a Steering Committee (analogous to the DSM Task Force). Five standing Review Committees, with about 6 members each, will work with the Steering Committee to consider the evidence in support of the proposed change. Proposals submitted to the DSM web portal will first be reviewed by the Steering Committee, which will refer the proposal to the appropriate review committee if it appears that the evidence for the proposal is substantially likely to meet the criteria for approval.

The Review Committee will undertake whatever additional investigation might be needed, such as consultation with relevant experts. It will then forward the reviewed proposal back to the Steering Committee to decide whether the proposal is suitable to be posted for public comment.

If the Steering Committee determines that the proposal has met the criteria for approval, it will submit the proposal and a summary of the public comments for review by the Board of Trustees of the APA. Once approved, changes will be publicized by the APA and digital versions of the manual will be updated to reflect the change.

The DSM-5 web portal has identified 3 types of proposals that require substantial empirical support, each with explicit criteria regarding the type of evidence that is expected to be submitted. In general, proposals should include a thorough review of the relevant literature and the results of any secondary data analyses conducted by those making the proposal.

 proposals involve changes to an existing diagnostic criteria set that purport to markedly improve the validity, reliability, or clinical utility of a criteria set, or to substantially reduce identified deleterious consequences

 proposals involve the addition of a new diagnostic category, subtype, or specifier

 proposals entail deleting an existing category or subtype or specifier

Proposals involving corrections and clarifications of existing criteria that do not require empirical support (type 4 proposals) are being considered on an expedited basis by a subcommittee of the Steering Committee. Included here are instances of lack of clarity or ambiguity in the meaning of the wording of criteria or text; inconsistencies or contradictions within the text or criteria (eg, diagnostic criteria that conflict with corresponding descriptions in the text); and errors of omission or inadvertent inclusion.

The first set of proposed changes to DSM-5 since the web portal was opened for submissions are now being posted for public comment on the DSM-5 web site, with comments being accepted from November 22, 2017 until December 22, 2017.

The first proposal concerns the ICD-10-CM diagnostic codes that apply to situations in which in a patient taking a medication, which is capable of causing physiological dependence, that is being taken as prescribed (ie, not abused), a withdrawal syndrome in the context of stopping the medication develops. The ICD-10-CM codes currently listed in DSM-5 for the categories of Opioid Withdrawal, Sedative, Hypnotic, or Anxiolytic Withdrawal, Cannabis Withdrawal, and Stimulant Withdrawal apply only to cases of withdrawal that develop in the context of a diagnosis of a substance use disorder. This proposal involves a change to the coding notes for these conditions so that they include the ICD-10-CM codes, which apply to cases of withdrawal that occur in the absence of a substance use disorder.

The second proposed change involves the definitions of Other/Unspecified Depressive Disorder and Other/Unspecified Anxiety Disorder, categories respectively reserved for cases in which the patient presents with depressive (or anxiety) symptoms that do not meet diagnostic criteria for any of the specific depressive disorders (or anxiety disorders). Since DSM-III, patients who present with mood or anxiety symptoms that do not meet criteria for one of the specified DSM disorders receive a diagnosis of either an Adjustment Disorder (if there is an identified causative psychosocial stressor) or the appropriate depressive or anxiety residual category (eg, Atypical Depression in DSM-III, Depressive Disorder NOS in DSM-III-R and DSM-IV, and Other/Unspecified Depressive Disorder in DSM-5). To make Adjustment Disorder take precedence over the residual categories, the definition of the residual category must indicate that the residual category NOT be diagnosed if the criteria are met for an Adjustment Disorder. This exclusion for Adjustment Disorder, inadvertently omitted from DSM-5, has been added.

 The third proposal applies to situations in which a patient’s response to exposure to a traumatic stressor does not meet criteria for PTSD. According to DSM-5, if the duration of the symptomatic response lasted 6 months or less, the diagnosis should be Adjustment Disorder. If the symptoms persist for more than 6 months, however, the Adjustment Disorder diagnosis no longer applies, since the 6-month limit on duration has been exceeded. Such cases should be diagnosed instead as Other Trauma- and Stressor-related Disorder. To clarify that this is the correct diagnosis for such scenarios, the following example has been added to the definition of Other Specified Trauma- and Stressor-related Disorder: “Persistent response to trauma with PTSD-like symptoms (ie, symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months).”

 The fourth proposal corrects an error in the hallucinations dimension that is a component of the Clinician-Rated Dimensions of Psychotic Symptom Severity scale included in DSM-5 Section III (“Emerging Measures and Models”). The anchor points for the hallucination severity dimension incorrectly focus exclusively on the impact of voices on the patient, when it should instead include all types of hallucinations.

 The final proposal corrects an unintended discrepancy between the wording of the stressor criterion (criterion A) in Posttraumatic Stress Disorder and Acute Stress Disorder. Criterion A in PTSD requires “exposure to actual or threatened death, serious injury, or sexual violence,” whereas criterion A in Acute Stress Disorder includes “exposure to actual or threatened death, serious injury, or 

” (italics added). The correct wording for both versions of criterion A is “exposure to . . . sexual violence.”

This article was originally posted on 11/16/17 and has since been updated.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way towards the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances.

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

One of the most common questions regarding antidepressants involves strategies for switching medications. This is not surprising, considering that results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial drew attention to the high rates of initial treatment failure with first-line agents.

 More specifically, up to 65% of patients fail to achieve remission, and approximately half of all patients fail to achieve an adequate response from their first antidepressant medication trial. High treatment failure rates make it critical for prescribers to know how to safely and effectively switch antidepressants to ensure patient-treatment targets are met.

There is limited guidance on the efficacy and tolerability of various switch strategies, which makes it essential that providers have a strong foundation in the pharmacological properties of antidepressants to understand how pharmacokinetic and pharmacodynamic drug interactions affect patients during the switch period. For example, if a patient is completing a cross-taper to transition from an antidepressant that is a potent inhibitor of the cytochrome 450 metabolizing enzyme 2D6 (CYP2D6) (eg, bupropion, fluoxetine, paroxetine) to a new antidepressant metabolized primarily by CYP2D6, the serum concentration of the new medication will be elevated by the CYP2D6 inhibitor until the first medication is eliminated. This leads to slower titration of the second antidepressant.

An example of a pharmacodynamic drug interaction is the required 2-week antidepressant-free period after stopping an MAOI because of the risk of serotonin syndrome and hypertensive crisis from accumulated synaptic monoamines. Furthermore, providers must consider the severity of their patient’s mood symptoms and weigh it against the concern of adverse drug events. This may lead to a more rapid switch in the hope of realizing benefit from the new medication as quickly as possible.

Discontinuation syndrome can occur upon abruptly stopping or rapidly lowering the dose of an antidepressant. Symptoms of discontinuation syndrome associated with various neurotransmitter and receptor systems are summarized in 

. Withdrawal phenomena need to be considered based on the pharmacology of how specific antidepressant medications affect serotonergic, adrenergic, histaminergic, and cholinergic activity. For example, TCAs have significant anticholinergic properties. Therefore, rapid withdrawal of these agents may precipitate cholinergic rebound, which can be associated with vomiting, nausea, headache, sweating, and muscle spasms. Cholinergic rebound can also apply to other antidepressants with anticholinergic properties that may be discontinued abruptly, such as paroxetine.

Prescribers should focus on the pharmacology involved rather than on specific medication classes, as differences in pharmacology of drugs in the same class can be significant enough to induce disparate withdrawal syndromes. Another example of this might be abrupt discontinuation of SNRIs, which can result in serotonergic withdrawal in addition to increased gastrointestinal motility and urinary urgency due to loss of noradrenergic effects.

In the case of rapid discontinuation of mirtazapine, reports include hypertension, tachycardia, insomnia, and mild anticholinergic withdrawal.3 In the case of rapid discontinuation of MAOIs, potential symptoms may include flu-like symptoms, tachycardia, hypertension, restlessness, dysphoria, excitation, or psychosis.

The need to mitigate the risk of discontinuation syndrome is particularly important when directly switching antidepressants or rapidly decreasing the dose of the first antidepressant. Symptoms appear to be most common when antidepressants are taken for more than 6 weeks, especially those with short half-lives (eg, paroxetine, venlafaxine), or are discontinued abruptly.

 Fluoxetine has notably less propensity to cause discontinuation syndrome because of its long half-life of 4 to 16 days (when taking into consideration its active metabolite, norfluoxetine).

 Patients are more likely to experience discontinuation syndrome when they have had difficulty tolerating an antidepressant during the initial phase of treatment.

 describe various management approaches to minimize discontinuation syndrome symptoms when stopping or lowering the dose of antidepressants. In the case of severe withdrawal symptoms, they recommend restarting the antidepressant at the previous dose and initiating a slower taper. Although there was no consensus on best practice, many studies recommend at least 4 weeks of tapering the dose before discontinuing the medication. However, this is not always feasible in clinical practice. Ultimately, it is important for providers to monitor tolerability of the medication changes and to adjust the titration process according to individual reactions.

Switching strategies that we discuss are listed in 

. The direct switch approach can be employed if the first agent was used for a short period (< 1 week) or when switching between some SSRIs, SNRIs, and TCAs (for more details, see 

). It is best to switch to an equivalent dose when possible. If the agent was used for a long period, or the patient was taking a high dose of medication, the cross-taper method is recommended. Cross-tapering is beneficial for individuals who are at high risk for relapsing from any improvement gained with the first medication, or are prone to discontinuation symptoms. As a general strategy, it is best to taper over at least 4 weeks if the agent was previously taken for 6 weeks or longer, and reduce the dose of the first medication by 25% per week.

 The first medication can be reduced at a slower rate if discontinuation symptoms were experienced previously, or if the patient is not tolerating the initial switching strategy.

When completing a cross-taper, it is also important to be aware of available dose formulations to avoid instructing the patient to take doses that are not feasible during the taper. Both the direct switch and cross-tapering methods have increased risk of drug-drug interactions when compared with a conservative switch strategy that utilizes a washout period of no medication. In practice, this approach is rarely attempted, with the exception of discontinuing an MAOI. Fluoxetine also has specific recommendations because of its long half-life, as detailed in 

 may be used as a general guide for switching between antidepressant medications.

There are many patient-specific factors that affect how rapidly an antidepressant is switched or withdrawn when medication changes are made; practitioners must treat patients on an individualized basis. Factors such as withdrawal from the old antidepressant, discontinuation syndrome, or washout periods can prolong the achievement of remission, and successful switching may take several weeks to months. This may seem overwhelming to an already at-risk population, since it leads to further-protracted treatment response.

Clinicians should strongly encourage patients to closely monitor for adverse effects when switching agents. Milder adverse events will dissipate with time, but severe, life-threatening events require immediate medical attention. Each switch strategy must be tailored to the patient and realistic expectations given to help optimize treatment success.

Ms. Soreide is a third-year pharmacy student at the University of Michigan College of Pharmacy. Dr. Ward is Clinical Assistant Professor, the University of Michigan College of Pharmacy, and Clinical Pharmacist in Psychiatry, Michigan Medicine, Ann Arbor. Dr. Bostwick is Associate Chair and Clinical Associate Professor, Department of Clinical Pharmacy, University of Michigan College of Pharmacy and Clinical Pharmacist in Psychiatry, Michigan Medicine, Ann Arbor.

 Rush AJ, Trivedi MH, Wisniewski SR, et al. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. 

 Bhanji NH, Chouinard G, Kolivakis T, Margolese HC. Persistent tardive rebound panic disorder, rebound anxiety and insomnia following paroxetine withdrawal: a review of rebound-withdrawal phenomena. 

 Howland RH. Potential adverse effects of discontinuing psychotropic drugs: part 2: antidepressant drugs. 

 Warner CH, Bobo W, Warner C, et al. Antidepressant discontinuation syndrome. 

 Keks N, Hope J, Keogh S. Switching and stopping antidepressants. 

 Wilson E, Lader M. A review of the management of antidepressant discontinuation symptoms. 

 Ogle NK, Akkerman SR. Guidance for the discontinuation or switching of antidepressant therapies in adults. 

 Howland RH. Potential adverse effects of discontinuing psychotropic drugs. Part 1: Adrenergic, cholinergic, and histamine drugs. 

 Hirsch M, Birnbaum RJ. Switching antidepressant medications in adults. UpToDate. 

https://www.uptodate.com/contents/switching-antidepressant-medications-in-adults

High treatment failure rates make it critical for prescribers to know how to safely and effectively switch antidepressants to ensure patient-treatment targets are met.

Strategies and Solutions for Switching Antidepressant Medications

It’s that time of year again. We polled our editorial board and our newly constituted advisory board of early career psychiatrists. This year we asked about the best and worst things relating to our field. As always, we received a diverse group of responses. While there were no transformational advances, I’m sure you’ll agree there is progress in many areas and a variety of topics that provide food for thought. Although the comments are excellent, space limitations prevent us from publishing all that we received.

Dr. Brian Miller selected the FDA approval of valbenazine as the most important event/development in psychiatry in 2017.

 Valbenazine is the first FDA-approved drug for the treatment of tardive dyskinesia. Several others, including Dr. Renato AlarcÃ³n, suggested the increasing study of formerly banned substances such as ketamine and psilocybin as important avenues for future medication development.

My choice for one of the most important advances this year involves the meta-analysis published several months ago in the that compared cognitive behavioral therapy (CBT) with psychodynamic therapy outcomes.

 The article reports that treatment outcomes for depression are similar between CBT and psychodynamic therapies. Given the assertions in recent years by CBT researchers that its effectiveness is the most highly substantiated by research studies, this publication’s conclusions come as welcome news for practitioners of psychodynamic therapies.

Dr. John Torous told us, “One of the ‘best’ things we are seeing is evidence and research beginning to catch up with digital mental health. While there is still much out there that we do not know, we are now beginning to see real data that are helping us begin to actually evaluate apps on their merits vs marketing claims.”

Along the same line of innovation, Dr. Awais Aftab chooses the FDA announcement that it would permit marketing of the first mobile medical app (the reSET application, Pear Therapeutics) for the treatment of an array of substance use disorders. The app is prescription-only and used as an adjunct to standard outpatient clinical treatment and contingency management. It is approved to treat alcohol, cocaine, marijuana, and stimulant substance use disorders, but not opioid use disorder. Its approval was based on data from a multi-site 12-week clinical trial of almost 400 patients, in which app users showed a significant increase in adherence to abstinence. This is likely a harbinger of the future role of digital innovations and applications in psychiatric care.

Dr. Alarc Ã³n also emphasizes the increasing use of telepsychiatry as a way to reach out to communities deprived of specialized mental health resources.

Dr. Peter Buckley highlights this year’s passage of the NIH BRAIN initiative. Not only will this endeavor bring new funding for research to better understand the brain, but it will foster increased interdisciplinary research crucial to important advances.

Although psychiatrists report experiencing burnout at rates much lower than the majority of medical specialties, the reported rate is still more than 40%. Dr. Steve Moffic asserts that the increasing epidemic of burnout among psychiatrists and other physicians is one of the most important challenges facing our field. The emergence of organizational concern for this epidemic, including from the American Psychiatric Association, is hailed by him as one of the best things that happened this year. Although other medical specialties have been trying to increase wellness and reduce burnout for many years, psychiatry has not been on the forefront.

Re-envisioning mental illness and treatment

, says Dr. Helen Lavretsky, invites us to re-think how we see and approach “mental illness” in Western cultures.

 The film takes an anthropological approach to understanding the effects of mental illness on both the individual and society. Reminiscent of the work of Dr. R. D. Laing,

 and other works, the film also explores a growing movement that believes a psychological crisis can be an opportunity for growth and transformation, not just a manifestation of a disease.

In a similar vein, Dr. AlarcÃ³n highlights the positive psychiatry movement as an evolving conceptual formulation of the nature, characteristics, and practice of our field, based on notions cultivated in psychology and the social sciences. While this term was coined several years ago, Dr. AlarcÃ³n sees 2017 as a nodal point (ie, its inclusion in the medical school curriculum and residency training programs, and its acceptance as part of the natural role of psychiatry and psychiatrists) that entails going beyond purely clinical foci to embrace preventive, educational, and public health models as part of our permanent armamentarium. While many psychiatrists would argue these aspects have always been a part of the ideal view of psychiatry’s mission and approach, Dr. AlarcÃ³n sees that the positive psychiatry movement is of particular benefit in so-called special populations-those who are often neglected or set aside by a routine-based practice style.

Appointment of a psychiatrist to a high government post

On Dr. Phil Muskin’s “best” list for this year is the appointment of psychiatrist Elinore F. McCance-Katz, MD, PhD, to the newly created post of Assistant Secretary for Mental Health and Substance Use at SAMHSA. Dr. McCance-Katz reports directly to the Secretary of Health and Human Services, and thus becomes what is arguably the most influential person in the federal government regarding mental health. Dr. Muskin especially lauds the fact that she is a skilled psychiatrist who is not simply, like many other recent high-level federal administrators, an inexperienced political appointee, but brings many years of experience as a psychiatrist, especially with substance abuse, to the federal government.

Societal changes and mental health implications

At a time when human migration due to primarily manmade disasters is at an all-time high, Dr. AlarcÃ³n reminds us that just as societal disruptions, such as the ongoing Syrian war and the more recent forced migration of over 500,000 religious minority Rohingya people from Myanmar, cause mental distress, positive societal change, such as has occurred in his home country of Peru in 2017, can also have ameliorative mental health effects. He writes:

The way in which countries and people handle the painful memories of collective, socio-political conflicts of the relatively recent past, and obviously their mental health sequelae, has received constructive, even inspiring examples from 2 Latin American countries. Colombia has officially ended more than 5 decades of war between the government, 2 guerrilla organizations, and several so-called paramilitary groups that caused more than 260,000 deaths: during that conflict, 25,000 disappeared, almost 7 million were internally displaced, hundreds of thousands left the country, property was lost, families disintegrated, and devastating individual and collective emotional dramas were endured. By publicly renouncing the use of weapons, apologizing, and asking to be forgiven in the presence of the Pope, making what seem politically mature decisions, former guerrilla leaders and soldiers, military commanders, and politicians seem to be ready to start a new era in the country’s history.

In Peru, September marked the 25th anniversary of the capture of the leader of Shining Path (Sendero Luminoso), the sanguinary Maoist-oriented guerrilla group that declared war on the government in the mid-1970s and led bloody hostilities for almost 2 decades, causing close to 80,000 deaths and desaparecidos, and almost 600,000 displaced people. During the commemorations, the public debate and reflections about the war (exemplified by 4 books on the subject, a powerful film about the capture, editorial comments in different publications, and passionate pronouncements in the media and social networks) have shown a sober sense of analysis, objective consideration of the facts, their implications, and meaning in the present and for the future of a country successfully attempting to maintain political stability and solid economic development. The message for future generations, those who did not live the bloody realities of the war, is challenging but promising. And with it, the mental health of more than 30 million people (Peru’s current population) can also embrace hope and provide inspiration for other world regions entrapped in similar civil conflagrations.

War, mass murder, government inaction, and corporate discrimination

 mentioned the adverse effects of global disasters, both natural and manmade, on the mental health status of at least hundreds of thousands of people who suffer but have no access to even minimal psychiatric care. There were also comments about the increasing number of mass killings in the US, attributed by most politicians to individuals with mental illness.

To make an obvious point, all the large-scale epidemiological research across developed countries shows only a modest variation in the incidence of major psychiatric disorders. Yet, we know the US by far has the highest incidence of mass shootings. Thus, it makes little sense to attribute our problem to mental illness. The ubiquity of guns and their availability in the US is another much more obvious difference in our country, and it has little to do with illness prevalence or available treatment.

Another source of dismay was the lack of national action to reduce the incidence of suicide, or to address the ongoing epidemic of opiate addiction. The designation of the opiate addiction epidemic as a public health emergency has little meaning when the government makes no changes in response. Furthermore, the recent revelations about the role of a recent nominee for a high-level health appointment in the federal government in blocking legal redress against what should be illegal distribution of opiates by pharmaceutical companies tells us everything we need to know about the likelihood of government action.

Several board members noted the ongoing “outrageous behavior by insurance companies such as UHC” regarding discriminatory reimbursement policies for psychiatric treatment. One contributor wrote that in his location, “They continue to deny care to psychiatric patients, contending that psychotherapy is ‘not medically necessary.’” Policies like this ensure that those companies stay on our “worst” list every year.

The role of ketamine in current practice makes both our “best” and “worst” lists this year. Dr. Cynthia Geppert writes:

My choice is the rapid proliferation of ketamine clinics for depression. Readers of the psychiatric literature including Psychiatric Times are well-aware of the promising results of clinical research into the use of ketamine for depression, as well as the continued scientific hurdles that must be overcome for ketamine to fulfill its promise as a safe, effective, and widely accessible psychopharmacological intervention. These clinics were one factor contributing to a recent consensus statement on the use of ketamine in the treatment of mood disorders.

But what some readers may not know is how these clinics have capitalized on the enormous and desperate hope of many patients with severe and refractory mood disorders that have not responded to established therapies. Or that it is anesthesiologists-not psychiatrists-who run and staff many of these clinics, often with a psychologist involved in treatment. Ketamine is not approved for depression, so its use is off-label. How this expansion of ketamine use will affect future research and clinical care should unexpected serious adverse events occur is at best uncertain and at worst an ethical concern to the profession.

We’d like to hear about your reactions to our editorial board’s list and your own thoughts about the best and worst in 2017.

 Tasman A. Tardive dyskinesia: finally some good news. 

http://www.psychiatrictimes.com/psychopharmacology/tardive-dyskinesia-finally-some-good-news

 Steinert C, Munder T, Rabung S, et al. Psychodynamic therapy” as efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. 

 AlarcÃ³n RD. Positive psychiatry: an interview with Dilip V. Jeste, MD. 

http://www.psychiatrictimes.com/psychotherapy/positive-psychiatry-interview-dilip-v-jeste-md

 Sanacora G, Frye MA, McDonald W, et al, for the American Psychiatric Association (APA) Council of Research Task Force on Novel Biomarkers and Treatments. A consensus statement on the use of ketamine in the treatment of mood disorders. 

This year we asked about the best and worst things relating to our field. As always, we received a diverse group of responses.

The Best of Times, the Worst of Times: 2017

My doctor-wife squeezes her needle-nose tweezers and lifts the tiny knots high enough to snip with surgical scissors...

Wound Healing

Fibromyalgia is one of the most controversial diagnoses in the field of pain management.

 Some health care professionals believe that the symptoms of this disorder are primarily due to mental disorders, while others believe that it is a physical disorder and that any signs of mental disorders are secondary to the pain and other physical symptoms. It is clear that many symptoms of fibromyalgia can also be symptoms of mental disorders, and it can be difficult to differentiate between them.

1. The most current research indicates that fibromyalgia is a musculoskeletal disorder.

2. Which diagnostic screening instruments are considered to be the most useful for diagnosing fibromyalgia?

3. Chronic widespread pain is sufficient to make the diagnosis of fibromyalgia.

4. The diagnosis of fibromyalgia should be made only after other possible etiologies for widespread pain are excluded.

5. Current research indicates that mental disorders may be frequently misdiagnosed as fibromyalgia.

6. What form of therapy has been found to be most efficacious for the management of fibromyalgia?

7. What form of exercise appears to be most effective for the management of fibromyalgia?

C. The most effective form of exercise has yet to be determined

8. Opioids are the most effective analgesics for the management of fibromyalgia.

9. In addition to tramadol, which other medications have been found to be effective for the management of fibromyalgia?

10. What form of psychotherapy appears to be most effective for the management of fibromyalgia?

11. As of yet, there are no good predictive factors to determine which of the recommended therapies is most likely to benefit the individual patient with fibromyalgia.

For answers to this quiz, please see next page.

Although the etiology of fibromyalgia is still unclear, at the present time it is primarily viewed as a neurologic disorder.

Widespread Pain Index and Symptom Severity Scale. These instruments incorporate the American College of Rheumatology diagnostic criteria for fibromyalgia, which are the most widely used criteria.

Although pain in multiple parts of the body is the primary symptom of fibromyalgia, the diagnosis also requires multiple somatic symptoms, including fatigue, unrefreshing sleep, and cognitive impairment.

Because there are no diagnostic tests for fibromyalgia, the clinical diagnosis is based primarily on history and self-report of symptoms. Many other disorders, both physical and mental, can present with the same symptoms of fibromyalgia; it is therefore imperative to rule these out before making the diagnosis of fibromyalgia.

It can be difficult to differentiate depressive and anxiety disorders from fibromyalgia. They can present with symptoms similar to those of fibromyalgia, including widespread pain, and there are no diagnostic tests for them.

In my experience, many patients who actually have a primary mental disorder are given the diagnosis of fibromyalgia, although they do not fulfill the diagnostic criteria for it. There is still a widespread belief that if pain is secondary to a mental disorder, it is consequently not “real.” The outcome is that patients may interpret this as indicating that health care providers may not be taking their pain seriously.

Although all of these therapies have been found to be beneficial for fibromyalgia, the strongest evidence supports the use of exercise.

7. Answer: C. The most effective form of exercise has yet to be determined

As of yet, the most effective type of exercise for the management of fibromyalgia is still unclear.

In general, the opioids appear to be ineffective for the treatment of pain associated with fibromyalgia. The only opioid-containing drug that has been found to be effective for fibromyalgia is tramadol, which contains both an opioid and an SNRI. Studies show that most of the analgesic effect is attributable to the SNRI.

The SNRIs amitriptyline, milnacipran, and duloxetine and the anticonvulsant pregabalin have been found to be most efficacious for the management of fibromyalgia. However, it is uncertain whether these SNRIs are really more effective than other SNRIs, or whether pregabalin is more effective than other anticonvulsants, including gabapentin-or if it is just that they have been studied more than other medications in the same class.

In general, the SSRIs have been found to be far less effective than the SNRIs for any form of pain.

10. Answer: A. Cognitive behavioral therapy

Biofeedback and hypnotherapy have not been found to be especially efficacious for the management of fibromyalgia.

As with most forms of chronic pain, there is very little information as to which treatment is likely to be most effective for an individual patient.

1. Clauw DJ, Hiroshi U. Summary of the Fibromyalgia Research Symposium 2016 in Nagasaki. 

http://journals.lww.com/painrpts/Fulltext/2017/02000/Summary_of_the_Fibromyalgia_Research_Symposium.2.aspx

2. Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. 

3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 revisions to the 2010/2011 fibromyalgia diagnostic criteria. 

4. Hauser W, Perrot S, Sommer C, et al. Diagnostic confounders of chronic widespread pain: not always fibromyalgia. 

http://journals.lww.com/painrpts/Abstract/2017/06000/Diagnostic_confounders_of_chronic_widespread_pain_.2.aspx

Take this quiz on one of the most controversial diagnoses in pain management.

THE QUIZ/Fibromyalgia

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

To understand the role of stress in the manifestation of depressive symptoms.

At the end of this CE activity, participants should be able to:

• Describe the brain circuits associated with depressive symptom clusters

• Identify the multiple functions associated with reward systems (eg, anticipatory, consummatory)

• Explain how the frontal cortex affects cognition in depression

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

:This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and Psychiatric Times. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 1.5 

™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Serge Campeau, PhD, has no disclosures to report.

Bruce S. McEwen, PhD, (peer/content reviewer) has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Everyone experiences psychological stressors daily, which elicit relatively stereotypical and coordinated cognitive, behavioral, autonomic, and neuroendocrine responses orchestrated by the brain. These reactions are adapted to counter real or perceived threatening situations that normally safeguard individuals by maintaining or restoring physiological homeostasis. However, these adaptive reactions, when prolonged, chronic, or traumatic, come at physiological and metabolic costs and induce long-term neuroplastic modifications that are frequently linked with several psychopathologies, including MDD.

The sustained activation and neuroplasticity within and between multiple neural networks engendered by perceived stress are known to modify mood and affect, the experience of pleasure, cognition, somatic functions and, ultimately, survival. Advances in the neurosciences continue to elucidate the ways in which specific brain networks, together with several other organs, respond to stressful situations, and how these initially adaptive modifications progressively lead to clinical pathological states.

Although much work is still needed to achieve a more complete understanding of the mechanisms responsible for depressive disorder, progress in distinguishing symptom clusters, structural/functional modifications in associated brain networks, and innate genetic and epigenetic contributions, has shed light on this condition, which commands such high human and financial costs. This improved knowledge translates into more effective and targeted treatment approaches.

Continuing efforts in the nosology of major depression emphasize different symptom categories or endophenotypes that are intimately associated with the functions of distinct brain regions and networks. In a recent analysis, the 9 criteria for major depressive episodes from DSM-IV-TR (not considerably modified in DSM-5) were clustered into 4 “clinical content” subtypes of depression, including

Given the symptom variability upon presentation of a depressive disorder, an important question is the extent to which these content clusters and their underlying circuits are differentially regulated by stress. The following provides a description of how stress influences brain structures and functions, as they pertain to different symptom categories of MDD.

Prefrontal cortex, amygdala, hippocampus, and depressed mood

Prefrontal cortical networks have been linked to psychopathologies, including MDD. Human imaging studies suggest that modifications of functional prefrontal network activities and connectivities with the parietal cortex, amygdaloid, and hippocampal formations are intimately related to the depressed mood cluster, one of the two defining symptoms of major depression.

A relatively stable account of functional brain alterations in major depression includes hypoactivity of the dorsolateral prefrontal cortex with reduced functional connectivity with the posterior parietal cortex and hippocampal formation. This functional outcome is often concurrent with hyperactivity in the ventromedial prefrontal and lateral orbitofrontal regions. The prominence of negative valuation of the self/environment is correlated with hyperactivity in the medial prefrontal/orbitofrontal cortex network linked with the amygdala. Supporting anatomical and morphological evidence for structural modifications of prefrontal, amygdala, and hippocampal subregions in clinical depression indicates changes in regional volumes (gray matter), neural/glial cell numbers, neurogenesis, and cortical thickness, which are correlated with severity of mood symptoms.

As one of several etiologic factors, stress is a leading candidate related to the presentation of major depression. In agreement with epidemiological studies, laboratory studies in humans indicate that acute stress increases indices of negative mood while simultaneously reducing positive affect-outcomes that normally subside within 24 hours.

 An important question related to these findings is whether repeated stress is a necessary antecedent to eventually yield a diagnosis of major depression.

A deep dive into the role of stress in the manifestation of depressive symptoms.

Psychiatric Times Vol 34 No 12

Confusing Psychosis with Imagination

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Strategies and Solutions for Switching Antidepressant Medications

The Best of Times, the Worst of Times: 2017

Wound Healing

THE QUIZ/Fibromyalgia

Stress, Neural Plasticity, and Major Depression

Measuring Up on Mental Health?

The Best and Not So Great Articles of 2017

Technological Ventures Offer New Hope for the Future of Psychiatry

Telepsychiatry-Based Culturally Sensitive Collaborative Treatment

Introduction: Innovations to Improve Mental Health Outcomes

Leveraging Smartphones in Patient Care