Dr. Swartz is Affiliate Faculty, Oregon Health & Science University, Portland; Emeritus Faculty, Southern Illinois University School of Medicine, Springfield, Illinois; and Medical Director, Lutheran Community Services Northwest, Vancouver, Washington.

Visual Hallucinations Linked to Timolol Eye Drops

The visual hallucinations from timolol eye drops reported in your January cover story apparently resulted from local effects on retinal circulation rather than systemic effects.

 The hallucinations described were of geometric shapes. This resembles phosphenes, an ordinary response to disruption of retinal circulation, as from closing eyelids tightly for 5-10 seconds or from orthostasis. Phosphenes can also result from diseases affecting the retina (eg, MS).

For mechanism, the Psychiatric Times piece hypothesized only similar systemic effects of eye drops and a 10-mg oral dose. A drop of timolol 0.5% in each eye contains just one twentieth of 10 mg, so its systemic effects cannot be compared. Moreover, timolol is hydrophilic, so after systemic absorption, it does not normally enter the brain.

In treating anxiety disorders over 25 years I have given CNS-active beta-blockers to over 2000 patients with clinical benefit. For elderly patients I prefer pindolol, in younger adults betaxolol.

 None of the patients reported visual hallucinations or showed (or mentioned) cognitive impairment. Beta-blockers are well tolerated and safer than antipsychotics in anxiety disorders. The report about timolol should not be understood as stating that timolol causes psychosis. Moreover, changes in color vision are distortions, and your article should not have called them hallucinations.

This article was originally published on February 1, 2018 and has since been updated.

Visual hallucinations linked to timolol eye drops

3. Swartz CM. Sympathy for the sympathetic (nervous system). In series "Clinical Controversies." 

Articles

Timolol Does Not Cause Psychosis

practices psychiatry in Manhattan, New York. He continues to publish frequently on film, media, and popular culture. For many years, his cinema column appeared in Psychiatric Times. He has appeared frequently on national and international network and cable television programs including Good Morning America, Today, CBS Evening and Sunday News, PBS, CNN, Showtime, and BBC-TV. Please address communications to Dr. Greenberg at 

I’ve written about poker nearly as long as I’ve been playing it. I observed in these pages years ago that the game can be a great revealer of-but sometimes a great destroyer of-character, especially when one harbors the psycho-social and hereditary/genetic potential for compulsive gambling.

Gambling humor embraces the dark side. Poker argot is especially mordant. “Where’s Lennie?” asked one of my high-rolling patients about a legendary loser, absent from the tables for several months.

Came the laconic reply: “Lennie is in Poker Hospital…” meaning he was broke beyond redemption…possibly disappeared himself to elude loan shark thugs who would assuredly be playing castanets on his kneecaps with hammers if he didn’t pay up.

Molly Bloom, feisty heroine of the eponymous 

, wound up in poker hospital not from playing, but from running lavish underground poker games in LA and NY. Her “clients” were major Wall Street sharks, glitterati from the worlds of entertainment, sports, politics, and-to her final undoing-kingpins of the Russian mob.

No-Limit Texas Hold-em is the most popular form of poker today. You can easily google the rules, but it’s more enjoyable to learn them by watching 

(1998), the best poker picture ever lensed.

Each player-10 maximum-is dealt 2 down cards, which are then combined with a “window” of 5 common pasteboards. Betting proceeds before and after the window is flopped. The best 5-card hand wins.

The game looks disarmingly simple. In fact, it’s alarmingly complex. Any player can go “all in”-bet his or her entire stack-at any time during a round. The ability to bluff and suss out bluffing is crucial. Played for high stakes, the game requires extraordinary patience and battlefield courage. You strive to keep your head on straight during hours of boredom, punctuated by moments of sheer terror.

Fine players carefully bide their time until the right terrifying moment comes along. But Molly’s punters were action junkies, many pathological gamblers who were always all in, creating stratospheric pots. Molly was especially adept at winkling out “fish,” poor players with deep pockets, able to sustain formidable losses and come back week after week for more .

She took great pride running a legitimate game in a milieu prone to knavery. She paid her employees-dealers, servers, security-on the books, kept scrupulously to the letter of ambiguous gaming laws. She lived large, but only on big weekly tips.

Aaron Sorkin’s previous TV and theatrical work-eg, in 

-featured high octane plotting and rat-a-tat dialogue reminiscent of the screwball comedies and sizzling crime pictures of Hollywood’s studio era. 

 marks his debut as a film director; he also adapted the film from Bloom’s autobiography.

Sorkin’s skillset satisfyingly drives the picture until an unfortunate conclusion, of which more presently. (Molly is stunningly played by Jessica Chastain). In the scorching establishing sequence, Federal agents summarily yank Molly out of bed and into the slammer for illegal gambling. Her arrest came several years after she had closed her operations.

The feds actually cared little about Molly’s games. They jailed her with the goal of compelling her to rat out 30 badfellas under indictment who had played at her tables. But Molly refused to co-operate. She had substantial knowledge about her players’ private lives, and refused to break confidentiality so as not to shame them and their families. Their outside business wasn’t her business.

Sorkin adroitly interpolates Molly herself relating her picaresque, often harrowing backstory, and third person narration of her quest to escape incarceration. Her voiceover delivery is fast paced, ironic, curiously distanced-as if she’s describing someone else’s life in a galaxy far away. Staccato cutting accentuates Molly’s fragmentated modus vivendi-initially exciting, and terminally desolating.

Molly’s father (a one-note gruff Kevin Costner) is a charismatic psychology professor, who relentlessly helicoptered Molly and her 2 brothers to become academic and athletic super achievers.

We infer that the brothers accepted, indeed flourished, under their father’s iron tutelage. Molly brashly challenged and disrespected him at every step; yet identified with his Ayn Randish vision of a world in which the meek are crushed and the elite rewarded.

Molly rose to early prominence in breakneck downhill ski racing, until a freak accident demolished her career. She migrated to LA against her father’s wishes and without his support. She became the factotum of a repellant Hollywood wanabee mogul. She serviced, then stole his game; eventually moved to Manhattan, where she ran more games at higher stakes.

Her judgement eventually deteriorated under escalating self-generated stress. She became drug-addicted, brought key Russian mobsters and an FBI informant to her tables. After refusing to partner up with the Mafia, she was shockingly beaten, then recovered her senses; fled back to California, got herself straight, and lived under the radar until her arrest. Making bail reduced her to penury. The Feds had already confiscated her savings, and taxed them to boot.

Molly’s players were all men; and crooked timber to a man. Their crude narcissism could gag a goat. The majority constituted an omnium gatherum of gambling addicts-perennial chasers after Lady Luck-massive losers who offered every rationale in the sordid book for behavior ruinous to others as themselves. Her biggest winner, no addict, was an odious predator who delighted in demolishing his opponents’ self-esteem as much as savaging their bankroll. Molly’s prosecutors are portrayed as no less repugnant. Utterly devoid of pity, they’d happily let her rot in jail if she didn’t co-operate. (Intriguingly, her punters from the Russian mob left their vicious psychopathy outside Molly’s doorstep: in the film they come across as hapless, even likeable schlubs.)

Charlie Jaffey (the estimable Idris Elba), a prominent criminal lawyer, proves a shining exception to the prevailing male grottiness. Jaffey’s fee is high as his probity. He takes her case-probably pro bono-because he’s captivated by her sass, wit, and staunch, if naÃ¯ve to compromise her people. By her lights, what went on outside the game room-sports betting, prostitution-weren’t her concern. All that mattered was running a pleasurable, profitable man-cave.

At the end, her case is unexpectedly thrown out by a benevolent judge. Her father also shows up with glib park bench psychoanalyzing, and a sappy declaration of love, dripping with crocodile tears. The reconciliation sequence strikes precisely the wrong bathetic note, in a solidly winning picture with a hollow Tinseltown heart. Watching it is akin to quaffing a good wine with a two-buck-chuck finish.

 has generally drawn excellent reviews. A few dissenters complained that Molly comes across as a stick figure, sans depth and complexity. Hollywood usually doesn’t “get” pathological gambling, glamorizing or demonizing it. Whatever his penchant for wearisome liberal pieties, Sorkin deserves credit for being spot on about the disorder’s psychopathology.

Pace the Goldwater ruling, the onscreen Molly Bloom’s shallowness isn’t due to vapid scripting, but the peculiar alexithymia native to the pathological gambler’s persona, which breeds massive unknowningness about inner life and motivations.

By this token, Molly is absolutely unable to register the dubious legality-and morality-of her games. Her insensate craving for “action” is another classic manifestation of the disorder: it precipitated the sinister slalom that ground down her ego strength and eroded her mortality (one notably sees this in end-stage gambling).

Molly also is fatally susceptible to the “gambler’s fallacy”-the unshakeable conviction that no matter how dire her straits, the odds will inevitably turn in her favor. Her gallows humor comprises yet another signature of the disorder.

I’ve elsewhere described pathological gambling as the dark underbelly of the American dream. It’s implied that by nurture or nurture, Molly has inherited her father’s cynical world view: if you’re not a stone-hearted winner, you’re a feckless loser.

Sorkin leaves Molly existentially unmoored, broke but not broken, already scanning the horizon to reinvent herself in some fashion. Given the dog-eat-dog tenor of the (Washington) times, her character pathology, ferocious intelligence, and ruthless ambition would seem to make going into politics a viable career option.

NB: For more information on pathological gambling, the reader is directed to Dr. Greenberg’s chapter on the subject in the latest edition of the Comprehensive Textbook of Psychiatry. His review of Rounders, which originally appeared in the now defunct Poker Pro magazine, can be found on the internationalpsychoanalysis.net website. 

This article was originally published on February 13, 2018 and has since been updated. 

The game looks disarmingly simple. In fact, it’s alarmingly complex.

Molly’s Game: Poker Hospital and Pathologic Gambling 

Adage: A short statement expressing a general truth.

Our patients’ lives consist of the stories they tell us. These stories describe their pathological symptoms, the vicissitudes of their childhoods, their recent victories and disappointments, their concerns about the future, and often and most importantly, their heartbreaks and longing for love and affection.

Just as patients organize their lives around the stories they tell us, we too sometimes respond to them with stories of our own. Over the years, I have found a number of metaphors, adages, and even a parable to be helpful in letting my patients know that they have been heard and to provide them with psychological comfort and support. The stories that we tell our patients have an element of a good-enough mother telling her children bedtime stories before they fall off to sleep. What follows are a few of the “stories” that I use in my psychodynamic psychotherapy practice with my patients, followed by brief reflections about each one.

1. Though no one can go back and make a brand-new START, my friend, anyone can start from now and make a brand-new END (Anonymous).

This adage is written on a small plaque that hangs on the wall of the bathroom used by my patients. As platitudinous as it is, it offers a message of hope to patients who are mired in unhappy reminiscences of their past and who believe that if only they had not experienced certain early maltreatment, their lives would be perfect.

This brief statement is relevant to the college student who dropped out the previous semester and is starting over again, to the recently divorced mother who feels that she is damaged and will never find another life partner, to the drug- or gambling-addicted patient who has suffered a multitude of self-inflicted losses and who believes that his or her past behavior will put its inevitable and irreversible stamp on
the future.

2. The difference between plants, non-human animals, and human beings is that plants exist in relationship to space, non-human animals live in the moment, and human beings have the capacity to conceptualize the future and the past.

I heard these definitions from a neuroscientist and futurist who spoke at a synagogue in Washington, DC, about 10 years ago. Patients’ anxiety about how things will turn out in the future can interfere with their ability to function in the present, and patients who believe that because they have failed at something in the past, fear that they will inevitably fail in the future. I sometimes cite Michael Jordan in this regard, the incomparable Chicago Bulls basketball forward who, I was told, when he missed a shot, immediately put the missed basket out of his mind and took another shot, not letting the failed shot interfere with his ability to keep scoring.

Dogs and cats, unlike people, probably don’t think about what they will be having for their next meal, or about what they ate last night, but we, human beings, are able to think about the future and to recall the past. In both instances, this has advantages and disadvantages. Being able to think about the future allows us to plan ahead and to anticipate and look forward to enjoyable events. But this also allows us to worry that things will not work out in the future, creating anxiety. Being able to reminisce about the past allows us to recall pleasant experiences with their accompanying glow of good feelings. At the same time, however, this ability to reminisce can fill us with regret about lost opportunities, failed grades, and the excruciating pain accompanying memories of relationships washed up on the rocky shores of broken hearts. Therefore, we will often do better if we can be more like dogs and cats that live in the moment and are not preoccupied with past regrets or anxiety about the future. This idea goes along with the current interest in mindfulness and other ways of “living in the moment.”

3. A companion adage is: To increase the likelihood that you will have the best possible future, have the best possible day today.

A number of college students in my practice struggle academically because they do not go to class or they procrastinate with their homework. I point out that if they are able to do their homework now and prepare today for their exam at the end of the week, they will graduate college with a higher GPA and will have more choices when they apply to graduate school or begin a career.

Lest I come across as sounding overly superficial, I am also interested in hearing about what is getting in the way psychologically of these students doing their work. That is, who are the authority figures in their lives that they are unconsciously trying to frustrate, why are they afraid of being too successful, and why are they getting drunk and high on marijuana every night?

4. If you are on an airplane, and the plane loses cabin pressure, put the oxygen mask on yourself first before putting it on the person sitting next to you (United Airlines, Southwest Airlines, American Airlines, etc).

This adage is for those patients who are trying to save others from disastrous interpersonal or economic situations, while not taking adequate care of their own needs first. The patient is often fearful that the other person will be angry if he or she does not give all of his or her money, possessions, etc, to the dependent person. I see this in patients in their 60s who have children in their 30s living at home, and who are not working full-time, are not in school, are heavily smoking pot, and are being supported by their aging parents. The parents are terrified that if they set limits on their children-ie, insist that they must get a full-time job and move out of the house by a certain date-their son or daughter will commit suicide. There is a powerful element of projected, denied, and disguised aggression directed toward their children. These parents can also feel unconsciously omnipotent about continuing to care for their “impaired” children.

The similar theological adage, God helps those who help themselves, is credited to Algernon Sidney and was later used by Benjamin Franklin in his Poor Richard’s Almanac of 1736.

5. The word “should” should be removed from thedictionary (Gerald P. Perman, MD).

“Should” indicates “an obligation, a duty, or correctness, typically used when criticizing someone’s actions.” This word is used in situations in which the patient is hypercritical of himself or herself, or of another person. This humorous adage will hopefully cause the listener to reflect on their castigating or self-castigating behaviors, and take steps to become more compassionate both toward oneself and toward others.

6. “I had a drink, the drink had a drink, and the drink had me” (Unknown Southern American writer).

This anthropomorphic (“. . . the drink had a drink, and the drink had me”) statement about alcoholism captures the overwhelming quality of addiction, the helplessness that many addicted patients experience, and the powerlessness of many alcoholics to stop drinking in an abusive fashion without getting help. I quote this to patients who drink too much but are not sure whether they fall into the category of someone suffering from alcohol abuse disorder. To mix my metaphors: “If the shoe fits, wear it.”

7. “You can please some of the people all of the time, all of the people some of the time, but you can never please all of the people all of the time” (Attributed to Abraham Lincoln as well as John Lydgate).

This quote was first used in the political sphere, but it is equally applicable in psychotherapy with overly perfectionist patients who tend to see things in an all or nothing manner, perhaps with borderline personality disorder features, and who therefore have difficulty making and accepting compromise.

Patients readily see the humor in this well-known adage, as well as its veracity, making it easier to accept and to help effect personality change.

8. The best way to keep a bird is to let it go free (Unknown source).

This beautiful adage comes from the more complete poetic quotation: “If you love something, set it free. If it comes back, it’s yours. If not, it was never meant to be.”

It is useful with patients who are overly controlling toward others, usually in the context of a romantic relationship. The gist of this idea is that (unless one is a sadist) we would only want to be in a relationship with someone who wants to be in a relationship with us.

This point can be driven home by turning it around and asking: “Would you want someone to be in a relationship with you, not because she loves you, but only because she doesn’t want to hurt your feelings if she leaves?”

The powerful idea expressed in this adage is also an extremely useful principle in managing the relationship between the therapist and the patient. That is, psychodynamic psychotherapy is a delicate procedure based at times on a tenuous therapeutic relationship.

It is crucial that the therapist create an environment in which the patient only continues in treatment because he or she feels that it is in his or her best interest to do so. Therefore, unless the patient is under a legal order to remain in treatment, we always want to leave the door open, so to speak, allowing the patient to feel free to leave anytime. This is how we keep our patients in treatment for a sufficient amount of time to give them the help they are coming to us for in the first place.

This article was originally published on February 16, 2018 and has since been updated. 

Dr. Perman reports no conflicts of interest concerning the subject matter of this article.

Over the years, I have found a number of metaphors, adages, and even a parable to be helpful in letting my patients know that they have been heard and to provide them with psychological comfort and support.

Advantageous Adages in Psychodynamic Psychotherapy

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is Associate Professor, Departments of Psychiatry and Medical Genetics, University of British Columbia, Vancouver, BC

Clinicians across all disciplines-including psychiatry-are increasingly feeling pressure to incorporate genetics into their clinical practice. Psychiatrists can find themselves confronted with their patients’ questions about whether genetic testing is an option that might provide useful answers for them. However, many psychiatrists lack confidence in their abilities to integrate genetics into their patient care.

Genetic counseling is a field at the forefront of the integration of genetics into clinical practice across a wide variety of medical specialties. In this article, I draw on experience from our specialist psychiatric genetic counseling service to provide practical guidance for psychiatrists who wish to confidently address the questions regarding genetics that may be posed by patients and their families.

Given that there are misconceptions about genetic counseling, before considering what it IS, it is first important to explicitly consider what it is NOT:

1. Genetic counseling is not genetic testing: Genetic counseling does not require genetic testing, nor in fact, even the availability of genetic testing for meaningful patient benefits to be derived from genetic counseling.

2. Genetic counseling is not simply a discussion with a family of a child’s risk for a condition of concern. Within the field of medicine, there is a perception that a conversation between a health care professional and a patient that concerns a child’s risk for an indicated heritable condition is “genetic counseling.” In fact, genetic counseling is a 50-year-old professional discipline, with accredited MSc level training programs throughout North America, certification boards, and in some states, licensure.

The work can involve addressing issues about a child’s risk for a condition of concern when it is relevant; but this constitutes only one facet of a wide range of issues that can be addressed. Genetic counselors work across an enormous range of medical specialties (eg, psychiatry, oncology, neurology, cardiology).

3. Genetic counseling is not a purely educational/informational intervention. Although information is a critical component, ideally the information is not simply delivered, but rather it is a discussion in the context of a psychotherapeutically-oriented encounter.

4. Genetic counseling is not limited to a discussion of the genetic contributions to a specific illness. In the context of a serious illness (eg, a psychiatric disorder), genetic counseling involves discussion of how genes, environmental exposures, and experiences interact to precipitate illness.

 by the National Society of Genetic Counselors (NSGC) as the: “process of helping people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease.”

 Genetic counseling is founded in a Rogerian, patient-centered approach and ideally is neither purely educational, nor purely counseling-based; but rather melds the 2 components seamlessly. Genetic counseling requires the gathering of information from, and the provision of information to the patient in a 2-way exchange designed to generate a shared understanding, all of which unfolds in the context of a supportive encounter.

Genetic counseling in the context of psychiatric disorders

The information-gathering element of psychiatric genetic counseling involves uncovering the patient’s existing explanation for the cause of illness, understanding his or her current illness management strategies, and eliciting and documenting a detailed psychiatric family history.

Patients' existing explanations for the cause of their condition is fundamentally important to genetic counseling. Patients’ existing explanations for the cause of their psychiatric illness (eg, “its my fault that I have schizophrenia, because I smoked too much pot when I was young) often invoke emotional reactions (eg, guilt, shame), which can influence how people engage with treatment. New information regarding the cause of illness is easily rejected if it is not explicitly discussed in the context of the patient’s existing explanation.

The information-provision element of genetic counseling involves using the patient’s personal and family history to contextualize evidence-based information about:

• Factors that have been associated with the development of the indicated condition

• Strategies that individuals might use to protect their mental health (eg, sleep, exercise, nutrition)

• When requested, communicating about risk for family members (eg, existing or potential children) to develop the indicated condition

Because the information that is discussed in genetic counseling is

, but rather “… loaded, creating affective, cognitive and behavioral reactivity”

 the counselor attempts to identify, expose, and address emotional issues related to guilt, fear, and shame that arise during the session in relation to the discussion about the causes of illness.

Genetic counseling-when delivered as described above (that is, without genetic testing)-can produce statistically significant increases in patients’ levels of empowerment and self-efficacy that are of a magnitude (d values of approximately 1 and 0.4 respectively) that suggests clinical significance.

 Indeed, theoretically, psychotherapeutically-oriented genetic counseling enables people to engage in lifestyle modifications that can lead to improved mental health. [see 

Genetic testing for psychiatric disorders

At present, there are no genetic tests with which to establish, confirm, or refine a psychiatric diagnosis. And, while 

 suggest genetic testing as a first-line approach to developmental disabilities (eg, autism), there are no guidelines that suggest a similar approach to genetic testing in the context of psychiatric conditions.

There is no doubt that testing for copy number variation syndromes (eg, 22q11.2 deletion) is appropriate in the context of a known family history of the syndrome, or in the context of a patient who presents with psychiatric illness together with other phenotypic features suggestive of the condition (eg, tetralogy of fallot, hypernasal speech, learning difficulties). However, the utility of screening for copy number variations in all individuals who present with psychiatric disorders as adults is unclear, especially given the frequency of variations of unknown significance and uncertainties regarding psychiatric illness. Although it remains an area of extensive research, there is currently only a single example of 

 that suggest that identifying a copy number variation could be used to inform psychiatric treatment strategy.

Psychiatric genetic counseling improves treatment adherence 

"Bob," aged 40 years, first experienced mental health problems in his mid-20s and shortly thereafter received a diagnosis of schizoaffective disorder. Since that time, his mental health has generally been poor. Bob’s psychiatrist had prescribed psychotropic medication but Bob felt that he did not need medications to be mentally healthy. Bob sought genetic counseling because he wanted to better understand the causes of his mental illness.

A first step in the counseling process involves asking the patient to describe what he or she perceives to be the cause of their illness. Bob attributed his illness to weak character, and the fact that he had used cannabis extensively as a teenager. He acknowledged the role of genetics in contributing to psychiatric disorders at the level of the population, but didn’t feel that this played a role in his own specific case. He felt that if he could only try harder, he would be OK; his ongoing difficulties made him feel like a failure.

A detailed psychiatric family history was taken showing that both of Bob’s parents had experienced significant mental health problems. Using visual counseling aids, Bob was shown that it was very likely that he had inherited a genetic vulnerability to mental illness from his parents. He broke down and was able to articulate that he felt “that a weight of guilt had been lifted,” and that he could see “for the first time, that perhaps it’s not all my fault.”

One month later, Bob was doing much better psychiatrically than he had in years. This was the result of his thinking about pharmacological treatment. Once he understood that genetics had played a role in his own illness, pharmacotherapy started making sense. He was now taking his medication as prescribed and doing well.

Psychiatric genetic counseling can engage people in self-care strategies to improve mental health 

"Jane," aged 50, had a job she loved and was good at. She also lived with bipolar disorder. Her colleagues knew about it and were very supportive, but her mental health was not good, and she was taking a lot of time off for depression. Jane decided to go for genetic counseling because she was concerned about her daughter’s risk for bipolar disorder, which she felt could happen “any day now.”

When asked what she thought the cause of the bipolar disorder was, Jane’s said simply, “genetics.” She had experienced a slew of really awful events in a very short time before her diagnosis, but didn’t think that this had anything to do with her illness.

The genetic counselor explained that bipolar disorder is caused by the combined effects of genetics and life experiences and showed her how her own experiences may have contributed to the development of the disorder. When Jane understood this, she was horrified. She said that she would never have told anyone that she had bipolar disorder had she known that it was not 100% genetic for fear that they would blame her. Counseling helped her work through the fear and shame-she began to see that the events that had contributed to her illness were not things that anyone could be blamed for. Aside from taking medication, she was not doing much else to take care of her mental health. Jane was advised about sleep, nutrition, exercise, and social support that can be helpful. It was suggested that by using some of these strategies together with her medication, her mental health might improve. Implementing these strategies could also protect her daughter’s mental health too. It was NOT a foregone conclusion that her daughter would receive a diagnosis for the same disorder.

Within a month of counseling, Jane had lost 10 pounds, she was going for a walk every day, she was doing her best to eat a healthier diet, and she was working to get better quality sleep.7 She was going to mindfulness classes with her daughter, and was trying a new medication. Her mental health was much better than it had been in years.

Genetic counseling compared with other interventions

While genetic counseling can certainly be conceptualized as a highly circumscribed and time limited form of psychotherapy, it is distinguishable from other forms of therapy by its incorporation of state-of-the-art understanding of the causes of the indicated condition, and its focus on addressing emotional issues. The impact on patient outcomes of psychiatric genetic counseling vs other therapies has yet to be explored, but compared with a purely educational approach regarding genetic and environmental contributors to illness, outcomes have been found to be better.

Genetic counseling is about more than simply genetic testing, and/or having conversations with patients regarding risk to children for developing a condition a family member has experienced. We clinicians might feel that research needs to have established a complete understanding of the genetic underpinnings of psychiatric disorders (or at least a genetic test of clinical utility) for genetic counseling to be relevant. However, clinical experience has shown that patients benefit from psychiatric genetic counseling even without validated evidence.

[Note: The vignettes in this article are fictional, based on a composite of many individuals who have sought psychiatric genetic counseling.]

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 Austin J. Psychiatric Genetic Counseling. 

https://www.youtube.com/watch?v=PqnxqMnPk_g

 Resta R, Biesecker BB, Bennett RL for the National Society of Genetic Counselors’ Definition Task Force. A new definition of genetic counseling: National Society of Genetic Counselors’ task force report. J Genet Couns. 2006:15:77-83.

 Veach PM, Bartels DM, Leroy BS. Coming full circle: a reciprocal-engagement model of genetic counseling practice. J Genet Couns. 2007:16:713-728.

Inglis A, Koehn D, McGillivray B, et al. Evaluating a unique, specialist psychiatric genetic counseling clinic: uptake and impact. Clin Genet. 2015;87:218-224.

 Miller DT, Adam MP, Aradhya S, et al. Consensus statement: chromosomal microarray is a first-tier clinical diagnostic test for individuals with developmental disabilities or congenital anomalies. Am J Hum Genet. 2010;86:749-764.

Butcher N, Fung WLA, Fitzpatrick L, et al. Response to clozapine in a clinically identifiable subtype of schizophrenia: 22q11.2 deletions mediate side effect risk and dosage. Br J Psychiatry. 2015:206:484-491.

 Austin J, Semaka A, Hadjipavlou G. Conceptualizing genetic counseling as psychotherapy in the era of genomic medicine. J Genet Coun. 2014;23:903-909.

 Hippman C, Ringrose A, Inglis A, et al. A pilot randomized clinical trial of the impact of genetic counseling for individuals with serious mental illness. J Clin Psychiatry. 2016;77:e190-e198.

 Leach E, Morris E, White H, et al. How do physicians decide to refer their patients for psychiatric genetic counseling? A qualitative study of physicians’ practice. J Gene Coun. 2016;25:1235-1242.

 Peay HL, Austin JC. How to Talk With Families About Genetics and Psychiatric Illness, 1st ed. New York, NY: WW Norton Co; 2011.

 Inglis A, Morris E, Austin J. Prenatal genetic counseling for psychiatric disorders. Prenat Diag. 2017;37:6-13.

 Austin J, Peay HL. Applications and limitations of empiric data in provision of recurrence risks for schizophrenia: a practical review for healthcare professionals providing clinical psychiatric genetics consultations. Clin Genet. 2006;70:177-187.

 Austin JC, Palmer C, Sheidley B, et al. Psychiatric disorders in clinical genetics II: Individualizing recurrence risks for psychiatric disorders. J Gene Coun. 2008;17:18-29.

 Ryan J, Virani A, Austin J. Ethical issues associated with genetic counseling in the context of adolescent psychiatry. Appl Transl Genom. 2015;5:23-29.

Practical guidance for psychiatrists who wish to confidently address questions regarding genetics that may be posed by patients and their families.

Genetics in the Clinical Setting: The Role of Psychiatric Genetic Counseling

Introduction: Lies, Dam Lies, and Statistics, by Allan Tasman, MD

I titled this column using the famous quote from Benjamin Disraeli, not because this column is about lying, but to illustrate the complexity of determining the validity of a statistical analysis. I’m referring specifically to a recent change implemented by NIMH regarding its assessment of the percentage of the population with schizophrenia, discussed in the accompanying analysis of the change by 

. While this might seem like an arcane academic issue, there are potentially very distressing real-world consequences.

Imagine, for example, if federal and state or local officials who fund already financially strapped community mental health centers (CMHCs) decided to make significant reductions in funding if they believe the actual numbers of patients with schizophrenia are much lower than those on which they calculated their original budget allocations. Since CMHC’s bear much of the burden of ambulatory care of those with schizophrenia, the impact could be devastating.

commentary by NIMH Director, Joshua A. Gordon, MD, PHD

, who explains the context of the NIMH decision-making process and the next steps.

HOCUS POCUS: How the NIMH Made 2 Million People With Schizophrenia Disappear, by E. Fuller Torrey, MD and Elizabeth Sinclair

A RESPONSE FROM THE NIMH DIRECTOR: On the Prevalence of Schizophrenia and Transforming Care Through Research, by  Joshua A. Gordon, MD, PhD

is Founder of the Treatment Advocacy Center and Associate Director for Research at the Stanley Medical Research Institute. 

is a Research Associate at the Treatment Advocacy Center.

Although he has been the Director of the National Institute of Mental Health (NIMH) for less than 2 years, Dr. Joshua A. Gordon has made 2 million individuals with schizophrenia disappear. NIMH has not said where they went but officially, they no longer exist. This is a remarkable accomplishment, especially given the lack of attention NIMH has given serious mental illness

Until November 2017, NIMH had claimed that the 1-year prevalence of schizophrenia in adults in the US was 1.1%. In other words, in any given year approximately 11 out of every 1,000 adults would be diagnosed with this disease of the brain. The Bureau of the Census estimated in 2017 that there were 252.1 million adults in the US; thus approximately 2.8 million would have been diagnosed with schizophrenia.

This estimate was based on the last major epidemiological study of serious mental illness in the US, the Epidemiologic Catchment Area (ECA) study. This NIMH-funded study sampled 5 areas (Los Angeles, St. Louis, New Haven, Baltimore, and rural counties in North Carolina) in the early 1980s. At least 3,000 adults living in households and 500 individuals living in mental hospitals, prisons, nursing homes and other institutions were directly interviewed in each area, then surveyed by telephone 6-months later and re-interviewed another 6-months after that. The results are considered to be the most accurate mental illness prevalence data available for the US. In 1993, at the request of the US Senate Committee on Appropriations, the ECA data were given to the Senate so that they could be used to assess the costs of these disorders. The ECA data have thus been the standard in the US for the past 3 decades.

Inexplicably, in November 2017, NIMH changed its website and declared that the 1-year prevalence of schizophrenia is now 0.3%, or 3 cases in 1,000 adults. Based on the current census estimates, this means that there are now only approximately 750,000 adults with schizophrenia each year in the US. Since there were 2.8 million previously, just over 2 million have been made to disappear.

How does NIMH justify this remarkable feat? They no longer make any mention of the ECA study and instead cite as the basis of their estimate a National Comorbidity Survey carried out in 2001-2003. This survey was a sampling of 9,282 people living at home and specifically excluded individuals in institutions, including in psychiatric or other hospitals, nursing homes, jails, prisons, homeless shelters, or individuals living on the street. Thus the official count of individuals with schizophrenia in the US now excludes anyone not living at home. The refusal rate for participating in the survey was 29%, and the authors cite a study reporting that people with paranoid symptoms are more likely to refuse to participate in such surveys. For screening their original sample of 9,282 people living at home, the study used the Composite International Diagnostic Interview (CIDI), a screening tool known to be poor in identifying individuals with schizophrenia. Among the original 9,282 persons, 2,382 had some psychiatric symptoms and were then screened using an instrument for non-affective psychosis (schizophrenia, schizoaffective disorder, delusional disorder, non-affective psychosis not otherwise specified). The final psychiatric diagnoses for this survey were based on telephone interviews with 73 people.

NIMH then tries to justify the use of a schizophrenia adult prevalence rate of 0.3% per year by citing 2 summaries of a worldwide prevalence study. This study included 188 prevalence studies, including the ECA study, carried out in 46 countries, some as early as 1935. The main finding of this study was the very wide range of prevalence in different countries, with the US being among the highest. Many of the studies were carried out in developing and rural countries that have reported a low prevalence of schizophrenia until recent years. Taking the median prevalence from these 188 studies to justify a current estimate for the US is scientifically irresponsible.

The new estimates from NIMH are also egregiously inconsistent with the majority of other prevalence estimates, even within the federal government. The latest data from the Substance Abuse and Mental Health Services Administration (SAMHSA) state that schizophrenia accounts for 22% of people with serious mental illness, or about 2.3 million adults based on current estimates. The Centers for Medicare and Medicaid Services reports that 4% of all Medicare beneficiaries have schizophrenia, increasing to 11.2% all individuals who are dual-eligible for Medicare and Medicaid. In addition, widely-cited academic literature has prevalence estimates consistently between 0.9%–1.1%.

Why did NIMH wish to massively reduce the official prevalence of schizophrenia in the US? In the past 2 years, members of Congress have become much more interested in problems associated with untreated severe mental illness. With the passage of the 21st Century Cures Act and appointment of the nation’s first Assistant Secretary for Mental Health in the Department of Health and Human Services, it seems likely that federal mental health agencies like NIMH may be held accountable in a way that they have not been previously. Having to account for 750,000 people with schizophrenia is much easier than having to account for 2.8 million. In addition, NIMH has already been widely criticized for ignoring the needs of individuals with schizophrenia, specifically by failing to support research on the development of new medications and other effective treatments.

It should also be noted that NIMH has not funded a major study to determine the current prevalence of schizophrenia since the ECA study in the early 1980s-more than 30 years ago. Thus we really have no idea whether the prevalence of schizophrenia has increased, decreased, or stayed the same. The lack of data in the US on this question stands in sharp contrast to almost every European country. In England, for example, 7 major studies on the prevalence of schizophrenia were carried out between 1986 and 2009, including studies of whether the prevalence is increasing; why the prevalence is so high among certain immigrant groups; and whether there are regional differences in prevalence. A measure of England’s interest in these issues is a 258-page report, “Systematic Review of the Incidence and Prevalence of Schizophrenia and Other Psychoses in England,” prepared for the Department of Health in 2012. The Scandinavian countries, of course, have even more sophisticated prevalence studies based on their national case registers. Compared with these countries, the data available in the US on the prevalence of schizophrenia are equivalent to the data available in some developing countries.

The last major study of the prevalence of schizophrenia in the US was carried out in the early 1980s. The results from that study have been used for 3 decades to estimate the annual prevalence of schizophrenia at 1.1% (11 in 1,000 adults). For unknown reasons, NIMH decided in November 2017 to no longer use that data. Instead, it adopted a 2001–2003 study that only assessed schizophrenia in people living at home. Individuals who are hospitalized, in nursing homes, in jail or prison, or homeless are no longer included in the measure of prevalence, which NIMH claims to now be 0.3% (3 in 1,000 adults). This decreases the number of people estimated to have schizophrenia in the US from approximately 2.8 million to 750,000. The very fact that NIMH would make such a change is a measure of the institute’s lack of interest and expertise on this important issue.

We have 2 recommendations that the agency should take to address this major discrepancy. First, it should restore the previous estimate of the prevalence of schizophrenia (1.1% annual rate for adults) until more updated data become available. Second, NIMH, perhaps in collaboration with SAMHSA, should undertake a major new study of the prevalence of schizophrenia, including individuals in psychiatric hospitals, in jails or prisons, and who are homeless. When Dr. Gordon became the Director of NIMH, he stated that his highest priority was to support good science. Let us hope that making individuals disappear is not representative.

Mental illnesses affect tens of millions of people in the US each year. As the lead federal agency for research on mental illnesses, the mission of the National Institute of Mental Health (NIMH) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery, and cure. NIMH, part of the National Institutes of Health (NIH), strives to provide the public with up-to-date, accurate information on our understanding of mental illnesses and the tremendous burden these illnesses pose to individuals and their families. To this end, we include prevalence statistics on our public-facing website to provide a framework for understanding the scope and impact of mental illnesses.

NIMH recently undertook an effort to refresh the statistics pages on our website, with respect to both design and content. For all statistics we report, our goal is to use the most accurate data available, which includes consideration of the most recent findings, as well as quality of the data. To help users understand and interpret the statistics we present, we aim to be rigorous and transparent by providing adequate background and context, as well as information on relevant strengths and limitations of the data sources. In the case of the refreshed schizophrenia statistics page, we used findings from several papers to approximate an estimate for the prevalence of schizophrenia. We now recognize, in retrospect, that we did not provide sufficient context to understand or justify the selected prevalence estimate, nor did the number we settled on reflect the full spectrum of knowledge available in the relevant literature.

Accurate and stable estimates of the prevalence of schizophrenia are made challenging by many factors. Comparisons across studies are hindered by inclusion of varying combinations of diagnostic criteria (eg, schizophrenia/schizophreniform; schizophrenia and other psychotic disorders; non-affective psychotic symptoms). The very definition of schizophrenia itself has changed over time since the DSM-III-based Epidemiologic Catchment Area (ECA) paper reported the prevalence of 1.1% in 1981.1 More recent surveys might under-count those with serious mental illness for many reasons, including the fact that many of these individuals decline to participate in surveys, or are homeless or incarcerated or otherwise difficult to reach. However, in the years since the ECA, a large number of studies, including several in the US, have clearly demonstrated that the 1.1% figure is no longer scientifically defensible.

But that does not mean the new figure we initially arrived upon – 0.3% – necessarily reflects the full picture. We are in the process of expeditiously reviewing and updating the information presented on our webpage to more fully reflect the available data on schizophrenia prevalence. We anticipate providing an estimated range, rather than a single point estimate; reporting such results will require inclusion of relevant caveats and limitations. More broadly, timely and accurate information on the prevalence of schizophrenia and other mental illnesses is important to multiple Department of Health and Human Services agencies beyond NIMH, including the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Centers for Disease Control and Prevention. By working together toward a solution to address the difficulties in estimating prevalence for schizophrenia and other serious mental illnesses, we can accomplish far more for our key stakeholders. NIMH looks forward to continuing to work collaboratively to advance these important objectives. I thank Dr. Torrey and Ms. Sinclair for bringing the need for this more thorough treatment of schizophrenia prevalence to our attention.

At the same time, I feel compelled to counter the notion that NIMH does not devote sufficient attention to serious mental illness. NIMH supports a diverse portfolio of research aimed at improving care for, and the lives of, individuals living with a serious mental illness. This research spans basic and translational sciences aimed at identifying and developing the breakthrough treatments of tomorrow, as well as services and intervention sciences aimed at optimizing and implementing the effective treatments of today.

For example, neurocognitive dysfunction is a hallmark of schizophrenia and represents an important, and untreated, component of the disability associated with the disorder. NIMH supports several cognitive remediation studies for individuals with psychosis aimed at improving cognition and functional outcomes. We are also supporting the development and testing of 3 novel compounds for their long-term potential to improve cognition in patients with schizophrenia.

NIMH funds several large-scale effectiveness trials of practical interventions to reduce premature mortality in people with serious mental illness by addressing health risk factors. Recognizing that modifiable health risks associated with premature mortality appear early, NIMH also funds research capitalizing on opportunities for early intervention with young people at high risk. Additional efforts test interventions aimed at improving overall functioning by focusing on employment, social engagement, and community integration. These are but a sampling of the many research projects of relevance to serious mental illness supported by NIMH.

Notably, NIMH-supported research is impacting people now. For example, the NIMH-funded Recovery After an Initial Schizophrenia Episode (RAISE) project, a large-scale comparative effectiveness research study, demonstrated that coordinated specialty care early in the course of treatment for first episode psychosis was superior to usual care in reducing symptoms, improving school and work functioning, and increasing quality of life. Importantly, the intervention tested in RAISE was found to be cost-effective. Based on results from RAISE, the Centers for Medicaid & Medicare Services extended Medicaid coverage for coordinated specialty care and SAMHSA set aside 10% of its Mental Health Block Grant allocation for each state to support evidence-based programs that target first episode psychosis. Today over 200 coordinated specialty care programs operate in 49 states, representing an unprecedented translation of scientific findings into services that directly benefit persons with early serious mental illness.

Most importantly, we must keep in mind that statistics, while useful, do not tell the full story of the tremendous burden shouldered by individuals and families living with schizophrenia, and the outsized impact this burden has on our society. NIMH will continue to aggressively support novel approaches to biological understanding, therapeutics development, and services and intervention delivery, all aimed at reducing this burden.

. Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85-94.

Here's a debate about a statistic the NIMH has posted on its website that, says one critic, significantly underestimates the number of adults with schizophrenia in the US and potentially affects their care. The Director of the NIMH responds.

Lies, Damn Lies, and Statistics

After he juggles three chainsaws and spins

twenty plates balanced on sticks, he moves

to the grand finale: ten Bowler hats tossed

across the arena and stacked on the ringmaster’s

head. He gets to nine and misses, and misses

the tenth three more times, cheers rising

to a roar with each failure, until the drum

rolls and the spotlight finds him for the final

of the stack and the audience stomps their praise.

After he juggles three chainsaws and spins twenty plates balanced on sticks, he moves to the grand finale: ten Bowler hats tossed across the arena and stacked on the ringmaster’s head.

Psychiatric Times Vol 35 No 3

Timolol Does Not Cause Psychosis

Molly’s Game: Poker Hospital and Pathologic Gambling

Advantageous Adages in Psychodynamic Psychotherapy

Genetics in the Clinical Setting: The Role of Psychiatric Genetic Counseling

Lies, Damn Lies, and Statistics

The Juggler

What’s in a Name? Name Changes for Subspecialty and the Academy of Psychosomatic Medicine

QT Prolongation and Antidepressants

PTSD in Late Life: Special Issues

HOCUS POCUS: How the NIMH Made 2 Million People With Schizophrenia Disappear

On the Prevalence of Schizophrenia and Transforming Care Through Research