Schizophrenia/Psychosis

In 2 previous editorials-“The ‘McDonaldization’ of Psychiatry” and “Doctor, Are You ‘Drugging’ or Medicating Your Patients?”-I focused on some serious problems in current psychiatric practice and on various shortcomings in our treatments. In the third “panel” of this editorial triptych, I want to take note of the considerable good that psychiatric treatment may bring to those who suffer with devastating illnesses.

Senator Charles Grassley (R-IA) is continuing his 2-year investigation of potential conflicts of interest between academic researchers and the pharmaceutical industry.

Until the early 19th century, psychiatry and religion were closely connected. Religious institutions were responsible for the care of the mentally ill. A major change occurred when Charcot1 and his pupil Freud2 associated religion with hysteria and neurosis. This created a divide between religion and mental health care, which has continued until recently. Psychiatry has a long tradition of dismissing and attacking religious experience. Religion has often been seen by mental health professionals in Western societies as irrational, outdated, and dependency forming and has been viewed to result in emotional instability.3

CATIE can be viewed as a switch study. Switches offer both opportunity and risk. Data from CATIE demonstrate differences in overall effectiveness, but these differences depend on the individual patient context.

On October 19, 2009, the Office of the Deputy US Attorney General issued a memorandum, “Investigations and Prosecutions in States Authorizing the Medical Use of Marijuana.”1 The memo announced a federal policy to abstain from investigating or prosecuting “individuals whose actions are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana.” The memo made clear, however, that it did not “legalize marijuana or provide a legal defense to a violation of federal law.” Rather, it was “intended solely as a guide to the exercise of investigative and prosecutorial discretion.”

Hy Bloom provided an expert psychiatric report in a multiple murder case in which the accused, who had schizophrenia and depression, had killed his wife and 2 children. Before the murders, the accused had been seeing a psychiatrist and family physician for treatment of the mental disorders.

It is my privilege and pleasure to highlight this Special Report on forensic psychiatry. (The first articles in this series appeared in the November issue and are posted on www.psychiatrictimes.com.) The respected authors provide us with the most recent thought on subjects that should be of interest to every practicing psychiatrist.

It is widely accepted that patients with schizophrenia have some degree of cognitive deficiency and that cognitive deficits are an inherent part of the disorder. Historically, there has been less focus on cognitive deficits in patients with bipolar disorder; however, numerous studies of cognition in patients with bipolar disorder, including several comprehensive meta-analyses of bipolar patients who were euthymic at the time of testing, have recently been undertaken.1-4 Each of these analyses found that cognitive impairment persists during periods of remission, mainly in domains that include attention and processing speed, memory, and executive functioning.4

New compounds and novel applications for established products were evaluated in many of the clinical trials reported at the recent 49th annual NIMH-sponsored New Clinical Drugs Evaluation Unit meeting.

November/December 2009 Special Report: Forensic Psychiatry

Award ceremonies abound, from the Oscars for film to the Clio awards for advertising, but none are as important to mental health and psychiatry as the NARSAD annual awards. NARSAD is a unique organization that is dedicated to mental health research, and the NARSAD awards are considered to be the most prestigious prizes in psychiatric research. On October 30, NARSAD presented its 22nd annual awards for outstanding achievement in mental health research. This year the prizes went to 8 distinguished scientists whose work is making a huge impact on the way psychiatric disorders will be diagnosed and treated.

Pediatric bipolar disorder (PBD) is a serious psychiatric illness that impairs children’s emotional, cognitive, and social development. PBD causes severe mood instability that manifests in chronic irritability, episodes of rage, tearfulness, distractibility, grandiosity or inflated self-esteem, hypersexual behavior, a decreased need for sleep, and behavioral activation coupled with poor judgment. While research in this area has accelerated during the past 15 years, there are still significant gaps in knowledge concerning the prevalence, etiology, phenomenology, assessment, and treatment for PBD.

Smoking cessation services should be integrated into substance use disorder treatment programs, according to David Kalman, MD, Department of Psychiatry, University of Massachusetts, and colleagues, in their recent review of tobacco dependency among patients who sought treatment for alcoholism.1

Appetite regulation is made up of complex interlocking, incentive-driven motivational hormonal and neuronal circuitries . . . that can be pulled in many directions, especially where food is cheap and readily available.

The FDA’s new rule on “expanded access programs” would allow pharmaceutical companies to give seriously ill patients broader access to investigational drugs outside of clinical trials. A limited number of expanded access programs were created in the past under sketchy FDA rules; the 2 new allied rules-one on the conditions drug companies must meet to create a program, the other on how they can charge for the drugs-ostensibly give pharma a wider berth. Moreover, psychotropic drugs can be provided under the clarified policy.

Surveys show that approximately 60% of the general population has gambled within the past 12 months.1 The majority of people who gamble do so socially and do not incur lasting adverse consequences or harm. Beyond this, approximately 1% to 2% of the population currently meets criteria for pathological gambling.2 This prevalence is similar to that of schizophrenia and bipolar disorder, yet pathological gambling often goes unrecognized by most health care providers.

>I greatly enjoyed Dr Ron Pies’ editorial “What Should Count as a Mental Disorder in DSM-V?”1 in which he encouraged framers of DSM-V to critically examine the boundaries of mental illness and to more carefully distinguish between diseases, disorders, and syndromes. As I have noted elsewhere, current plans to integrate a “spectrum” approach into DSM-V require a careful consideration of these issues that must be defensible to critics of diagnostic expansion within psychiatry.2

The FDA recently approved iloperidone (Fanapt, Vanda Pharmaceuticals) for the treatment of schizophrenia, reversing a July 2008 determination that the New Drug Application (NDA) was “not approvable.” An FDA spokesperson explained in an interview in Forbes (May 8), “Vanda provided the FDA with additional data and arguments that led us to reinterpret results of several of their studies.”

Strategies for Recognizing Schizophrenia and Treating to Remission

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.

A Different Approach to Treatment Resistance

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:

Since the inclusion of the borderline personality disorder (BPD) diagnosis in DSM, there have been multiple efforts to recast the disorder as part of an Axis I illness category. While the initial focus was on the schizophrenia spectrum, more recent authors have attempted to link BPD to mood disorders.

When the solution to a clinical or scientific puzzle eludes us for more than a century, as with schizophrenia, we need new methods to examine the pathology. If we want to make an impact on the disease we must shift research paradigms and focus on the early detection, early intervention, and new avenues of treatment that address different symptoms of schizophrenia.

Rages are part of a syndrome of severe mood dysregulation, which is defined by markedly increased and frequent reactivity to negative emotional stimuli.

New mental health coverage mandates going into effect in 2010 will force corporations and their insurance companies to adopt new utilization management protocols that could put the squeeze on psychiatrists.

PTSD filled a nosological gap by providing a way to characterize the long-lasting effects of trauma exposure.1 This led to a plethora of previously lacking scientific observations. Now the existence of PTSD is being called into question because some of the original assumptions that helped make the case for it have proved to be incorrect.2-4 However, it is possible to update some of the flawed assumptions of PTSD without rescinding the diagnosis. There is no reason to throw the baby out with the bathwater.

I have the highest respect and affection for Will Carpenter, MD, who wrote a recent response ("Criticism vs Fact: A Response To A Warning Sign on the Road to DSM-V by Allen Frances, MD," Psychiatric Times, July 7, 2009) to my earlier commentary, but we do differ sharply on the following points.

Through high-profile media cases and in film, the American public has had glimpses into the psychological phenomenon and criminal behavior known as stalking. But do these glimpses truly represent the types of stalking offenses that are commonly perpetrated? Academicians and public policy makers have only begun to focus attention on stalkingin the past 10 to 15 years. As is often the case, the dissemination of information relevant to treating clinicians often lags behind by many years. Thus, many mental health professionals have not been adequately trained to recognize stalking behavior and to treat those who perpetrate it.

Findings of a recent large population survey suggest that 1 in 3 adults in this country (approximately 72 million people) uses 1 or more complementary and alternative medicine (CAM) modalities during any given year.1 Many CAMs are widely regarded as safe on the basis of their established uses in traditional systems of medicine over centuries or longer and their current widespread use in the United States and other Western countries. Unfortunately, there is limited reliable information on potential risks associated with the majority of these approaches.