Psychiatric Times Vol 26 No 8

A National Academy of Sciences (NAS) report urging a more coordinated approach to prevention and treatment of depression in parents-because of its impact on children-hit the streets just as Congress began considering legislation to reform the US health insurance system. The NAS report made a number of recommendations for changing the approach of both public and private health insurers toward depression, although the front-line troops expected to deal with the problem are primary care physicians, who already treat 70% of patients with depression.

As a standing member of the Editorial Board of Psychiatric Times, I read with particular interest the front-page story in the March issue, “Pharmonitor: Reality-Checking and Journalistic Integrity” by Editor in Chief Ronald Pies, MD. In it, Dr Pies pointed out that “disclosures do not guarantee scientific or journalistic objectivity and accuracy.” He set out the critical scientific questions that ought to be asked, and he promised that “Pharmonitor” would be “a reader-driven commentary . . . focusing on articles and reports in Psychiatric Times that the reader considers biased.”

Although the onset of psychotic symptoms before the age of 13 years is exceedingly rare, the incidence of schizophrenia rises sharply after the onset of puberty.1 Only 1% of the population has schizophrenia and 30% of these patients experience an onset of psychotic symptoms by age 18 years.2-8 The period that precedes the onset of frank psychotic symptoms (ie, the prodromal phase) has not been well characterized in early-onset schizophrenia-spectrum disorders (EOSS), but retrospective reports have shown that symptoms include high levels of depression and anxiety, emerging cognitive and social deficits, unusual thought content, and (not infrequently) school failure.

I had intended not to reply to the silly suggestion made by the DSM-V leadership that I wrote my critique out of financial motivations. I had expected that we would be conducting a useful discourse on the concrete issues and was surprised by the unenlightening personal exchange. Unfortunately, the DSM-V leadership refuses to discuss any of the substantive questions I have raised and instead, I am told, persists in the shallow rationalization that whatever I say is about royalties.

What the New Mind-Body Science Tells Us About the Pathophysiology of Major Depression-Focus on Treatment

For pharmaceutical companies, off-label use of a drug represents a substantial “gray market,” to which the company is unable to sell their product directly, yet may be a significant revenue stream. Some drugs have been used more for off-label purposes than for originally approved indications.1

In a shot recently fired around the online world, commentary about the DSM-V process by Allen Frances, MD, has sparked heated debate that continues to reverberate around the psychiatric world.

Historically, borderline patients were considered “help-rejecting complainers.” Clinicians should actively treat both mood/anxiety symptoms and BPD symptoms.

A Different Approach to Treatment Resistance

The articles in this Special Report reflect the growing recognition of the importance of the problem of treatment-resistant psychiatric disorders.

This statistic is as familiar as it is startling. According to the National Comorbidity Survey-Replication (NCS-R), the peak age of onset for any disease involving mental health is 14 years. True for bipolar disorder. True for anxiety. True for schizophrenia and substance abuse and eating disorders. The data suggest that most mental health challenges emerge during adolescence. If true, this brings to mind an important developmental question:

There is currently a small but impressive evidence base that shows that psychological and interpersonal factors play a pivotal role in pharmacological treatment responsiveness.

The chances for full recovery from major depressive disorder diminish the longer a patient remains depressed-a fact that lends a sense of urgency for appropriate therapy.

I wrote, directed, coedited, and financed DisFigured because it’s a movie I wanted to see. I’m not a woman and I don’t have an eating disorder, but the issues of appearance, control, isolation, and our complicated relationships with our bodies seem universal to me. They are also sadly underexplored or horribly twisted in almost every form of media. I am particularly aware of this because my wife Jenn is beautiful, graceful, stylish and-according to popular culture-fat.

The commentary “A Warning Sign on the Road to DSM-5: Beware of its Unintended Consequences” by Allen Frances, M.D., submitted to Psychiatric Times contains factual errors and assumptions about the development of DSM-V that cannot go unchallenged. Frances now joins a group of individuals, many involved in development of previous editions of DSM, including Dr. Robert Spitzer, who repeat the same accusations about DSM-V with disregard for the facts.

We should begin with full disclosure. As head of the DSM-IV Task Force, I established strict guidelines to ensure that changes from DSM-III-R to DSM-IV would be few and well supported by empirical data. Please keep this history in mind as you read my numerous criticisms of the current DSM-V process. It is reasonable for you to wonder whether I have an inherently conservative bias or am protecting my own DSM-IV baby. I feel sure that I am identifying grave problems in the DSM-V goals, methods, and products, but it is for the reader to judge my objectivity.