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Here’s a very unscientific survey of this year’s most meaningful issues is psychiatry. Quite a year.
It’s been a really interesting year for psychiatry, to say the least. Because of that we decided to poll our editorial board and some of our most widely read contributors and their colleagues to get a very unscientific survey of this year’s most meaningful issues. I have a few of my own that I’ll save till the end, but here are some of our contributors’ responses.
Drs. Ronald Pies, Barbara Schildkrout, and Paul Summergrad all nominated the genomics and proteomics research that has given rise to incredible advances in our understanding of major psychiatric disorders like schizophrenia, bipolar disorder, and major depression. One study, cited by Ron Pies, identified genes that seem to commonly affect all 3 of these disorders and among other things relate to control of brain cell communication and immune responsiveness.1 Another report, mentioned by both Schildkrout and Summergrad, focuses on the role of the C4A gene in the development of schizophrenia and discusses the implication of the genetic findings and potential approaches this suggested disease mechanism has for treatment.2,3
One compelling aspect of these examples is the fact that the results come from exceptionally large groups of subjects. I recently heard a talk by one of the researchers describing a study with 40,000 patients. He noted that the state of the art level of expectation of significance in current genomic research now is 5 × 10-8. That’s an incredible change from commonly used research standards of 10-2.
Psychotomimetic agents for treatment
Drs. James Knoll, Steve Koh, and Michael First all mentioned work being done with ketamine for rapid-onset antidepressant effect, and its possible use in quickly ameliorating suicidal ideation. Ketamine, which got its very negative reputation in the 1960s, seems to work by an as-yet unknown mechanism. This research is important not only in the study of ketamine itself, but because, as James Knoll wrote, it offers an opening into studying other psychotomimetic agents, which have gone unexplored in recent decades.
Neuromodulation, imaging, biomarkers
Dr. Helen Lavretsky’s vote goes to the rapidly expanding field of neuromodulation research, and she refers us to 2 important books on the subject.4,5 The field offers a promise of mood and cognitive benefits for treatment of a variety of disorders. I can personally vouch for the importance of further work in this area, since in my own lab, we have used both rTMS and neurofeedback training in several studies that found benefits in the treatment of ADHD or autism.6,7
Other important areas of neuroscience research were mentioned by Dr. Jerald Kay. One study he notes from Nature, relates to the Human Connectome Project.8 Several hundred healthy young adults were studied, and 97 previously unidentified new specific areas in the cortex were found. He also highlights a study in which the relationship between early life stress and amygdala hyper-reactivity is investigated.9 While the lasting biological effects of early life stress have been known for decades, this study predicts with more than 80% accuracy the likely response to antidepressants in this population. It emphasizes the rapidly intensifying area of research aimed at identifying biomarkers associated with either specific diseases or treatment interventions. The study also suggests the potential utility of combining biological markers with other historical and/or psychological information to predict treatment response.
Several contributors voted for the long overdue attention to the epidemic of opiate addiction. I had written about this in an editorial earlier this year. In that column, I said that I was glad this issue was finally being addressed but chastised both the government and large medical organizations like the AMA that ignored the problem, about which psychiatrists had been long aware, which had spiraled out of control years ago.10 Dr. Thomas Kosten cites an article by Nora Volkow and colleagues11 that offers convincing evidence to a broad medical readership that standard prescribing practices for opiates are not tenable. They also highlight both prescribing practice changes and policy changes, including much better education starting at the medical school level and research aimed at developing new potent, but nonaddictive pain medications and nonpharmacological pain-treatment strategies. Nearly all her recommendations are embodied in the FDA and CDC guidelines for opiate prescribing.12
Several of our contributors mentioned social issues or phenomena. Dr. Cynthia Geppert notes the rising trend for states in the US to pass laws that legalize physician-assisted suicide. She cites the important Pies article published in Psychiatric Times about a new Canadian law with frightening prospects for catastrophic outcomes.13 Unlike other laws in the US or abroad, the Canadian law codifies physician-assisted suicide not only for a life-limiting illness but also for what the bill calls “intractable” mental illnesses-to include not only dementia but also disorders such as depression or PTSD.
The most, but not only, appalling component of the law is that it applies to minors as well as the elderly or others with terminal physical illnesses. Dr. Geppert writes, “ . . . ask yourself if you believe we can define what intractable means in psychiatry? Do we really know when a patient’s case is futile? Are depressed adolescents truly capable of a rational decision to die?” Of even greater concern, she notes that this law was changed without long study, rigorous research, or important debate, which usually precede major changes in mental health public policy.
Dr. Renato Alarcon focuses our attention on the global epidemic of violence and its psychological impact. He writes,
The August 16 photograph of Omram Daqueesh, the 5-year-old boy from Aleppo, Syria, looking dusty, bleeding copiously, stunned and weary, unable to understand the why and how of deadly airstrikes over his hometown, was the most dramatic representation of a human crisis of universal proportions.14 As a reflection of cruelty, fanaticism, neglect, and opportunism, this development showed the global impact of violence as an emotional and behavioral trait almost gone out of control. Violence and its many faces, its presence in multiple forms (war, crime, abuse, exploitation, homelessness, murder) practically all over the world (and the US is not certainly an exception), has become in 2016 the most formidable challenge to American and world psychiatry’s discourse, role, and actions as a professional, academic, and scientific endeavor. . . . psychiatry has witnessed this year a seemingly unstoppable, world-wide dehumanizing process. Studying its nature, educating society and fighting against the emotional wounds of violence to correct its erosive course, must gain prominence as the main objectives of our discipline now and in the future.
Parity and politics
In the government action arena, I was very pleased to see the October announcement of the release of the final report from the Obama administration’s Federal Parity Task Force. The report outlines action steps to strengthen insurance coverage for mental health and substance use disorders.15 The comprehensive and lengthy set of action items and proposed regulatory changes are encouraging and long overdue. My enthusiasm is tempered by the November elections and the likelihood that the incoming administration will not take the needed actions to implement the recommendations nor support ongoing funding.
And, speaking of the election, I feel compelled to say a few words. Dr. Steve Moffic wrote that he thought the important issue for us about the presidential election is that we should re-evaluate the strictures placed on members of the American Psychiatric Association by the “Goldwater Rule.” This APA policy was put into place following the 1964 presidential election when a number of psychiatrists publically stated their belief that Barry Goldwater had a mental illness. The rule prohibits saying such a thing about a person who we have not personally evaluated nor without that person’s permission. Personally, I think it’s a good rule, although I agree that there may well be value in revisiting it. I wrote earlier in the campaign about my views of the very low value of untrained people wildly throwing around diagnoses, and you can read it again if you wish.16
To me, the important take-home message of this campaign has less to do with evaluating the fitness of the candidates, but more what the election’s outcome tells us yet again about the role of empathy in politics. Whichever side you were on in the election, what’s clear is that decisions were made by many people not on their thoughts about the candidates. Nor did voters choose based on the strength of intellectual arguments. Their decisions in most cases, I believe, were based on their feelings about themselves and their own lives. The frustration, fear, and rage we saw, which led to an outpouring of votes for Donald Trump, was not invented by either Donald Trump or Bernie Sanders; it was already there. And like an empathic listening psychotherapist, the candidates who empathized with those feelings in the electorate, whether actual or feigned empathy, formed an alliance that led to lots and lots of votes and an electoral college victory (although at the time that I wrote this, Hillary Clinton was leading the popular vote).
Good psychotherapy does not primarily produce change through intellectual discourse but through engaging the emotional valance for certain cognitions in our patients-in my book, this is what won the election. Being a CNN and MSNBC addict (though I haven’t had much trouble going through withdrawal), I rarely heard any reference to those affects from the Democrats. The Republicans, at least since Nixon, have been masters at this, as is, for better or worse, the new President-elect.
There are lots of reasons anyone wins an election, including this one, but I think the politico-therapeutic alliance is a major factor that rarely gets much attention until the election postmortems. And then, the lessons are often forgotten. No one has to be well versed in Maslow’s hierarchy of needs pyramid to know that economic security, which supplies food and shelter, and safety/security for self and family are the most basic and primal. Bill Clinton, he of “I feel your pain,” and James Carville, he of “It’s the economy, stupid” (his exhortation to the campaign staff), and just last month, Donald Trump, are textbook examples. No one paying attention to this issue should have been surprised that Trump won, which in my view was due in large part to his bonding with voters around their affects stemming from economic insecurity (no job, no food or shelter, which leads to fear and insecurity about safety, which then often leads to rage).
One very important difference between therapy and politics, however, is that psychotherapists are well aware of the power of affects and their potentially harmful impact on the individual’s thinking and behavior. Because of this, we do our best to be exquisitely sensitive about modulating our interactions with our patients so that the individual is not overwhelmed and therefore maladaptive responses are kept in check. When political candidates for national office (this year we saw this at both the presidential and congressional level) not only empathize with strong dysphoric affects, but also mirror those intense affects in their own words and affects, what can be easily understood as fostering loss of usual constraints on maladaptive actions, it can unleash extremely worrisome consequences. And, to our great dismay, we have seen, both during the election campaign and its aftermath, the alarming rise in reported incidents of hateful speech and actions, often but not only by adolescents and young adults, directed against women and members of minority ethnic and racial groups.
And just a bit more
I can’t end this list of important issues from 2016 talking about politics, so just let me mention 2 other topics from the research world that made my own list. From Science magazine last February comes a report highlighting the role that maternal immune activation (as in Zika but other infections too) influences fetal brain development.17 This has been known for a long time, but has not been much of a subject for psychiatric research outside of decades-old explorations of a link between schizophrenia (or more recently autism) and maternal infection. Understanding the pathophysiology of this effect has tremendous implications for understanding the potential impact of prenatal maternal immune activation on many psychiatric illnesses.
Finally, I have to highlight the explosion of interest in the gut microbiome and its role in both physical and psychiatric disorders such as depression. While this field of research is really in its infancy, it has been known for ages that there are intimate connections between the gut and the brain. Now we are wondering what role our gut bacteria play in these processes. It is really like beginning to explore a whole new galaxy, and I’ll bet there is a great deal that pertains to mental functioning and psychiatric disorders awaiting discovery.
Well, it’s been an exhausting year, and if you’re still reading, this column has probably taxed your attention a bit, too. I hope everyone enjoys the holiday season, has time for at least a short break, and has a safe, healthy, productive and, more importantly, peaceful year.
1. Darby MM, Yolken RH, Sabunciyan S. Consistently altered expression of gene sets in postmortem brains of individuals with major psychiatric disorders. Transl Psychiatry. September 2016. http://www.nature.com/tp/journal/v6/n9/full/tp2016173a.html. Accessed November 10, 2016.
2. Sekar A, Bialas AR, de Rivera H, et al. Schizophrenia risk from complex variation of complement component 4. Nature. 2016;530:177-183.
3. Mukherjee S. Runs in the family. New Yorker. March 2016. http://www.newyorker.com/magazine/2016/03/28/the-genetics-of-schizophrenia. Accessed November 10, 2016.
4. Hamami C, Holtzheimer P, Lozano AM, Mayberg H, eds. Neuromodulation in Psychiatry. 1st ed. London, UK: Wiley-Blackwell; 2016.
5. Siegel DJ. Mind: A Journey to the Heart of Being Human. 1st ed. New York: WW Norton; 2016.
6. Sokhadze EM, El-Baz A, Tasman A, et al. Neuromodulation integrating rTMS and neurofeedback for the treatment of autism spectrum disorder: an exploratory study. Appl Psychophysiol Biofeedback. 2014;39:3-4.
7. Hillard B, El-Baz A, Sears L, et al. Neurofeedback training aimed to improve focused attention and alertness in children with ADHD: a study of relative power of EEG rhythms using custom-made software application. Clin EEG Neurosci. 2013;44:193-202.
8. Glasser MF, Coalson TS, Robinson EC, et al. A multi-modal parcellation of human cerebral cortex. Nature. 2016;536:171-178.
9. Goldstein-Piekarski AN, Korgaonkar MS, Green E, et al. Human amygdala engagement moderated by early life stress exposure is a biobehavioral target for predicting recovery on antidepressants. Proc Natl Acad Sci. 2016;113:11955-11960.
10. Tasman A. At last . . . I hope. Psychiatric Times. May 2016. http://www.psychiatrictimes.com/psychopharmacology/last-i-hope. Accessed November 10, 2016.
11. Volkow ND, McLellan T. Opioid abuse in chronic pain: misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253-1263.
12. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain: United States, 2016. http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed November 10, 2016.
13. Pies RW. Physician-assisted dying for adolescents with intractable mental illness? Psychiatric Times. May 2016. http://www.psychiatrictimes.com/blogs/physician-assisted-dying-adolescents-intractable-mental-illness. Accessed November 10, 2016.
14. Barnard A. How Omran Daqneesh, 5, became a symbol of Aleppo’s suffering. August 2016. http://www.nytimes.com/2016/08/19/world/middleeast/omran-daqneesh-syria-aleppo.html. Accessed November 10, 2016.
15. US Department of Health and Human Services. Mental Health and Substance Use Disorder Parity Task Force: Final Report. http://www.hhs.gov/about/agencies/advisory-committees/parity/index.html#report. Accessed November 10, 2016.
16. Tasman A. Whistle while you work, Stevenson’s a jerk. Psychiatric Times. September 2016. http://www.psychiatrictimes.com/cultural-psychiatry/whistle-while-you-work-stevensons-jerk. Accessed November 10, 2016.
17. Estes MK, McAllister AK. Maternal Th17 cells take a toll on baby’s brain. Science. 2016;351:919-920.