Friday, August 10, 2012

General Psychiatry Review - 8.10.12 - Mike Nova's starred items

Mike Nova's starred items - 2:49 PM 8/10/2012


Utility of DMDD diagnosis in child psychiatric patients questioned
By Andrew Czyzewski. In children admitted to a psychiatric unit with serious behavioral problems, use of the new diagnosis concept of disruptive mood dysregulation disorder (DMDD) may go some way to reducing diagnoses of bipolar disorder, research ...

August 9, 2012, 12:00 pm

The Bullying Culture of Medical School

Powerfully built and with the face of a boxer, he cast a bone-chilling shadow wherever he went in the hospital.
At least that is what my medical school classmates and I thought whenever we passed by a certain resident, or doctor-in-training, just a few years older than we were.
With the wisdom of hindsight, I now see that the young man was a brilliant and promising young doctor who took his patients' conditions to heart but who also possessed a temper so explosive that medical students dreaded working with him. He had called various classmates "stupid" and "useless" and could erupt with little warning in the middle of hospital halls. Like frightened little mice, we endured the treatment as an inevitable part of medical training, fearful that doing otherwise could result in a career-destroying evaluation or grade.
But one day, one of our classmates, having already been on the receiving end of several of this doctor's tirades, shouted back. She questioned one of his conclusions in front of the rest of the medical team, insisted on getting an explanation, then screamed back when he started yelling at her.
The entire episode unnerved us all; and over the next few weeks, we marveled at her courage and fretted over her potentially ruined career prospects. But there was one aspect of the event that disturbed us even more. One classmate who had witnessed the "screaming match" described how our fellow medical student had raised her voice and positioned her body as she threatened the doctor. "It was weird," he recounted. "It was like watching her turn into him."
For 30 years, medical educators have known that becoming a doctor requires more than an endless array of standardized exams, long hours on the wards and years spent in training. For many medical students, verbal and physical harassment and intimidation are part of the exhausting process, too.
It was a pediatrician, a pioneer in work with abused children, who first noted the problem. And early studies found that abuse of medical students was most pronounced in the third year of medical school, when students began working one on one or in small teams with senior physicians and residents in the hospital. The first surveys found that as many as 85 percent of students felt they had been abused during their third year. They described mistreatment that ranged from being yelled at and told they were "worthless" or "the stupidest medical student," to being threatened with bad grades or a ruined career and even getting hit, pushed or made the target of a thrown medical tool.
Nonetheless, many of these researchers believed that such mistreatment could be eliminated, or at least significantly mitigated, if each medical school acknowledged the behavior, then created institutional anti-harassment policies, grievance committees and educational, training and counseling programs to break the abuse cycle.
One medical school became a leader in adopting such changes. Starting in 1995, educators at the David Geffen School of Medicine at the University of California, Los Angeles, began instituting a series of schoolwide reforms. They adopted policies to reduce abuse and promote prevention; established a Gender and Power Abuse Committee, mandated lectures, workshops and training sessions for students, residents and faculty members; and created an office to accept confidential reports, investigate and then address allegations of mistreatment.
To gauge the effectiveness of these initiatives, the school also began asking all students at the end of their third year to complete a five-question survey on whether they felt they had been mistreated over the course of the year.
The school has just published the sobering results of the surveys over the last 13 years. While there appears to have been a slight drop in the numbers of students who report experiencing mistreatment, more than half of all medical students still said that they had been intimidated or physically or verbally harassed.
Students described being yelled at, pushed and threatened. One student recounted being slapped on the hand by a more senior doctor who said, "If teaching doesn't help you learn, then pain will." Some students wrote about racial insults, with senior staff members making noises to mimic a foreign language; others reported being grabbed, asked out on a date or passed over because of their sex.
"We were really crushed when we saw the results," said Joyce M. Fried, lead author of the paper and assistant dean and chairwoman of the Gender and Power Abuse Committee at the medical school. "We were disappointed that it was so difficult to change."
U.C.L.A.'s experience is not isolated. In fact, national medical education surveys that include questions about mistreatment indicate that the environment at that school is about average. And the striking similarity of experiences across a generation of students suggests problems not just with one institution, but with the culture of medical training itself. "This is a national problem," Ms. Fried said. "Our faculty and doctors-in-training come from all over, including schools where some of them might have been mistreated."
While their findings are disheartening, Ms. Fried and her colleagues continue to believe that medical student mistreatment can be significantly reduced - but only if all medical schools come together to work on the issue. "We're talking about the really hard task of changing a culture, and that has to be done on a national level," Ms. Fried said. Such an effort would include shared training programs, common policies regarding mistreatment and greater transparency about the mistreatment that currently exists in medical schools.
"There are a lot of really good people and role models out there," Ms. Fried said. "But the culture for all these years has been to just take the mistreatment and not say anything."
"It wasn't right back then, and it shouldn't be tolerated anymore," she added.

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via Clinical Psychiatry News by on 8/10/12
Symptoms of obsessive-compulsive disorder preceded symptoms of schizophrenia in 48% of 133 patients hospitalized over an 11-year period who had both disorders.
The obsessive-compulsive symptoms and...

Professor Solms was honoured with one of the biggest prizes in international psychiatry when, in January this year, he accepted the Mary S Sigourney Award, which recognises distinguished lifetime contributions to the field of psychoanalysis.

In fact, a pinnacle of his illustrious career is the way he helped advance the push for equal treatment of homosexuals by changing the psychiatric world's definition of gay. Again, from The Times: “Up into the 1970s, the field's ...

August 6, 2012, 5:26 pm

X-Ray Scans at Airports Leave Lingering Worries

Even before she was pregnant, Yolanda Marin-Czachor tried to avoid the full-body X-ray scanners that security officers use to screen airport passengers. Now she's adamant about it: She'll take a radiation-free pat-down instead any day.
"I had two miscarriages before this pregnancy," Ms. Marin-Czachor, a 34-year-old mother and teacher from Green Bay, Wis., recalled, "and one of the first things my doctor said was: 'Do not go through one of those machines. There have not been any long-term studies. I would prefer you stay away from it.' "
There are 244 full-body "backscatter" X-ray scanners in use at 36 airports in the United States. They operate almost nonstop, according to the Transportation Security Administration. Other airports use millimeter wave scanners, which look like glass telephone booths and do not use ionizing radiation, or metal detectors.
Most experts agree that as long as the X-ray backscatter machines are functioning properly, they expose passengers to only extremely low doses of ionizing radiation.
But some experts are less sanguine, and questions persist about the safety of using X-ray machines on such a large scale. A recent study reported that radiation from the machines can reach organs through the skin. In another report, researchers estimated that one billion X-ray backscatter scans per year would lead to perhaps 100 radiation-induced cancers in the future. The European Union has banned body scanners that use radiation; it is against the law in several European countries to X-ray people without a medical reason.
The machines move a narrowly focused beam of high-intensity radiation very quickly across the body, and David Brenner, director of the Center for Radiological Research at Columbia University Medical Center, says he worries about mechanical malfunctions that could cause the beam to stop in one place for even a few seconds, resulting in greater radiation exposure.
For security reasons, much about how the machines work has been kept secret. The T.S.A. says the full-body scanners have been assessed by the Food and Drug Administration, the United States Army Public Health Command and the Johns Hopkins University Applied Physics Laboratory.
But researchers at these institutions have not always had direct access to the scanners in use, and some of the published reports about them have been heavily redacted, with the authors' names removed. Independent scientists say limited access has hampered their ability to evaluate the systems.
John Sedat, emeritus professor of biochemistry and biophysics at the University of California, San Francisco, believes that the effective dose could be 45 times as high as the T.S.A. has estimated, equivalent to about 10 percent of a single chest X-ray.
T.S.A. officials scoff at scientists' statements that measuring the effective radiation dose received by passengers is very complex, saying that it is not difficult, that the machines are inspected for problems at least once a year, and that they are equipped with fail-safe shutoff systems.
The machines, though, have had mechanical problems. A recent T.S.A. report said that between May 2010 and May 2011, there were 3,778 service calls concerning mechanical problems in backscatter X-ray machines. Radiation safety surveys were conducted after only 2 percent of the calls.
In a letter to the federal Department of Health and Human Services dated Oct. 12, 2010, the scientists said that "the casual nature for maintenance of these devices is alarming to us. These machines are capable of delivering large X-ray doses.
They added, "Hospitals usually check for problems on X-ray machines daily."
Most of what is known of the risks of radiation has been extrapolated from disease trends in Japan after World War II.
T.S.A. officials say that these low doses of radiation are safe for everyone, including pregnant women, infants and young children, even though children are significantly more sensitive to radiation's effects.
Those at greatest risk, however, may be T.S.A. employees and others who work in the terminals and go through security daily. A 2004 National Institute for Occupational Safety and Health study of T.S.A. baggage screeners urged the agency to have employees wear film badges to monitor ongoing exposure systemically, as many hospital and lab employees do, and to label machines more prominently. The agency has not done so.
While the risk to the average passenger may be low, here are some suggestions for those who wish to reduce their exposure.
¶ Get to the airport early. That gives you extra time to opt for a pat-down if you want.
¶ If you are pregnant or think you may be pregnant, tell a T.S.A. agent. You may be allowed to pass through a metal detector without additional screening.
¶ The younger children are, the more sensitive to radiation. T.S.A. employees have been known not to require children under 13 to go through an X-ray machine, although the agency denies there is any policy on this.
¶ If you have any concerns about medical conditions, you have the right to opt for a pat-down by a T.S.A. employee.
Readers may submit comments or questions for The Consumer by e-mail to
This post has been revised to reflect the following correction:
Correction: August 8, 2012

An earlier version of this article described millimeter wave scanners incorrectly. The scanners, which look like glass telephone booths, do not use ionizing radiation, but they do use low-powered radio frequency waves; it is not the case that they use no radiation.

Appropriate cancer screening and efforts to reduce smoking and other modifiable risk factors for cancer are imperative in patients with serious mental illness, researchers say.
Medscape Medical News

via BMC Psychiatry - Latest Articles by Dov Aizenberg on 8/9/12
Background: Clinical and psychosocial remission amongst persons with schizophrenia is nowadays a defined goal of treatment. This necessitates incorporating quantifiable psychosocial variables with traditional symptomatic data. We aimed to assess clinical and psychosocial remission in schizophrenia in a large cohort of community dwelling persons with schizophrenia. We emphasized between-groups comparison of antipsychotic medications and administration methods on the outcome of remission. Methods: Psychiatric case managers rated psychosocial remission using the PsychoSocial Remission Scale (PSRS) and clinical remission using the Remission in Schizophrenia Working Group symptomatic remission criteria (RSWG). Ratings were performed for persons with schizophrenia they have been treating for 6 months or more. Data as to gender, age and pharmacological treatment of each patient were also collected. Results: Of 445 participants who completed the survey, 268 (60%) were evaluated by psychiatrists, 161 (36%) by nurses and 16 (4%) were evaluated by social workers. Patients mean age was 43.4 + 13.1 years; 61% were men and 39% were women. Antipsychotic treatments were as follows: Per-os (PO) 243 (55%), IM long-acting typical antipsychotics (LAT) 102 (23%) and IM long-acting risperidone (RLAI; Consta) 100 (22%). Overall, 37% of patients achieved symptomatic remission and 31% achieved psychosocial remission. Rates of symptomatic remission were significantly higher in patients treated by LAT and RLAI compared with PO (51% and 48% vs., 29% respectively, p = 0.0003). Rates of psychosocial remission were also significantly higher in patients treated by LAT and RLAI compared with PO (43%% and 41% vs., 24% respectively, p = 0.003). Conclusion: In a large national sample a third of persons with schizophrenia were in remission. IM long acting preparations were associated with higher remission rates. Treatment choice may thus influence rates of remission in persons with schizophrenia.

via NYT > Health by By LISA SANDERS, M.D. on 8/10/12
Readers solve the mystery of a 31-year-old woman with thyroid disease who drives herself to the emergency room because of palpitations and a very slow heartbeat.

See more of Mike Nova's starred items ...


  • Outcomes and moderators of a preventive school-based mental health intervention for children affected by war in Sri Lanka: a cluster randomized trial.
    We aimed to examine outcomes, moderators and mediators of a preventive school-based mental health intervention implemented by paraprofessionals in a war-affected setting in northern Sri Lanka. A cluster randomized trial was employed. Subsequent to screening 1,370 children in randomly selected school... We aimed to examine outcomes, moderators and mediators of a preventive school-based mental health intervention implemented by paraprofessionals in a war-affected setting in northern Sri Lanka. A cluster randomized trial was employed. Subsequent to screening 1,370 children in randomly selected schools, 399 children were assigned to an intervention (n=199) or waitlist control condition (n=200). The intervention consisted of 15 manualized sessions over 5 weeks of cognitive behavioral techniques and creative expressive elements. Assessments took place before, 1 week after, and 3 months after the intervention. Primary outcomes included post-traumatic stress disorder (PTSD), depressive, and anxiety symptoms. No main effects on primary outcomes were identified. A main effect in favor of intervention for conduct problems was observed. This effect was stronger for younger children. Furthermore, we found intervention benefits for specific subgroups. Stronger effects were found for boys with regard to PTSD and anxiety symptoms, and for younger children on pro-social behavior. Moreover, we found stronger intervention effects on PTSD, anxiety, and function impairment for children experiencing lower levels of current war-related stressors. Girls in the intervention condition showed smaller reductions on PTSD symptoms than waitlisted girls. We conclude that preventive school-based psychosocial interventions in volatile areas characterized by ongoing war-related stressors may effectively improve indicators of psychological wellbeing and posttraumatic stress-related symptoms in some children. However, they may undermine natural recovery for others. Further research is necessary to examine how gender, age and current war-related experiences contribute to differential intervention effects.
    World psychiatry : official journal of the World Psychiatric Association (WPA). 11(2):114-22.

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via The Lancet by Dennis Altman, Peter Aggleton, Michael Williams, Travis Kong, Vasu Reddy, David Harrad, Toni Reis, Richard Parker on 7/27/12
The first cases of AIDS were identified in gay men in the USA, and the disease was originally termed gay-related immune deficiency (GRID). Mobilisation of attention and resources was slow, partly because of the association between AIDS and male homosexuality and corresponding reluctance on the part of government officials to acknowledge the importance of the epidemic. 25 years later, the same reluctance is evident in many parts of the world, and again, scarcity in attention and resources is affecting responses to HIV transmission in homosexual men.

via The Lancet by Chris Beyrer, Patrick S Sullivan, Jorge Sanchez, David Dowdy, Dennis Altman, Gift Trapence, Chris Collins, Elly Katabira, Michel Kazatchkine, Michel Sidibe, Kenneth H Mayer on 7/27/12
Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments.

via The Lancet by Gregorio A Millett, William L Jeffries, John L Peterson, David J Malebranche, Tim Lane, Stephen A Flores, Kevin A Fenton, Patrick A Wilson, Riley Steiner, Charles M Heilig on 7/27/12
Pooled estimates from across the African diaspora show that black men who have sex with men (MSM) are 15 times more likely to be HIV positive compared with general populations and 8·5 times more likely compared with black populations. Disparities in the prevalence of HIV infection are greater in African and Caribbean countries that criminalise homosexual activity than in those that do not criminalise such behaviour. With the exception of US and African epidemiological studies, most studies of black MSM mainly focus on outcomes associated with HIV behavioural risk rather than on prevalence, incidence, or undiagnosed infection.

via The Lancet by Gift Trapence, Chris Collins, Sam Avrett, Robert Carr, Hugo Sanchez, George Ayala, Daouda Diouf, Chris Beyrer, Stefan D Baral on 7/27/12
Community leadership and participation by gay men and men who have sex with men (MSM) have been central to the response to HIV since the beginning of the epidemic. Through a wide array of actions, engagement of MSM has been important in the protection of communities. The connection between personal and community health as drivers of health advocacy continue to be a powerful element. The passion and urgency brought by MSM communities have led to the targeting and expansion of HIV and AIDS research and programming, and have improved the synergy of health and human rights, sustainability, accountability, and health outcomes for all people affected by HIV.

via The Lancet by Patrick S Sullivan, Alex Carballo-Diéguez, Thomas Coates, Steven M Goodreau, Ian McGowan, Eduard J Sanders, Adrian Smith, Prabuddhagopal Goswami, Jorge Sanchez on 7/27/12
Men who have sex with men (MSM) have been substantially affected by HIV epidemics worldwide. Epidemics in MSM are re-emerging in many high-income countries and gaining greater recognition in many low-income and middle-income countries. Better HIV prevention strategies are urgently needed. Our review of HIV prevention strategies for MSM identified several important themes. At the beginning of the epidemic, stand-alone behavioural interventions mostly aimed to reduce unprotected anal intercourse, which, although somewhat efficacious, did not reduce HIV transmission.

via The Lancet by Kenneth H Mayer, Linda-Gail Bekker, Ron Stall, Andrew E Grulich, Grant Colfax, Javier R Lama on 7/27/12
Men who have sex with men (MSM) have unique health-care needs, not only because of biological factors such as an increased susceptibility to infection with HIV and sexually transmitted infections associated with their sexual behaviour, but also because of internalisation of societal stigma related to homosexuality and gender non-conformity, resulting in depression, anxiety, substance use, and other adverse outcomes. Successful responses to the global HIV/AIDS epidemic will require the development of culturally sensitive clinical care programmes for MSM that address these health disparities and root causes of maladaptive behaviour (eg, societal homophobia).

via The Lancet by Chris Beyrer, Stefan D Baral, Frits van Griensven, Steven M Goodreau, Suwat Chariyalertsak, Andrea L Wirtz, Ron Brookmeyer on 7/27/12
Epidemics of HIV in men who have sex with men (MSM) continue to expand in most countries. We sought to understand the epidemiological drivers of the global epidemic in MSM and why it continues unabated. We did a comprehensive review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and modelled the dynamics of HIV transmission with an agent-based simulation. Our findings show that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM.

via The Lancet by Konstantinos N Fountoulakis, Melina Siamouli, Ilias A Grammatikopoulos, Sotirios A Koupidis, Pavlos N Theodorakis on 7/27/12
Essentially we agree with Marina Economou and colleagues that reducing suicide rates, or preventing their rise, are challenges not only for psychiatry but for the whole of society. The time series published in July, 2012, by the Greek Statistics Authority does not suggest any increase in suicide rates throughout the decade: the number of completed suicides for 2010 was 377, similar to that of 2009 (391) and 2008 (373). As we have suggested, and Economou and colleagues agree, attempts and reported attempts or suicidal thoughts are quite different from completed suicides.

via The Lancet by Marina Economou, Michael Madianos, Lily E Peppou, Christos Theleritis, Costas N Stefanis on 7/27/12
Konstantinos Fountoulakis and colleagues (March 17, p 1001) state that there is no evidence of a causal link between the economic crisis and suicide in Greece. Although only a cohort study would enable causal inferences, converging evidence from different sources points towards a similar direction: efforts should be focused on prevention of suicides.

via The Lancet by David Holmes on 7/27/12
A new era in HIV prevention began last week with the approval of a combination pill containing two antiretroviral drugs for use in HIV-negative individuals. David Holmes reports.

via The Lancet by Richard Horton on 7/27/12
UNAIDS and WHO have signed a historic “letter of agreement” that begins the gradual repositioning of AIDS within global health. Michel Sidibé and Margaret Chan (Executive Director of UNAIDS and Director-General of WHO, respectively) have signed a new covenant setting out the terms of their strategic collaboration. Their commitment to one another is an unprecedented alignment between two agencies that have more often behaved as rivals than partners. They will now work together to integrate AIDS and non-communicable disease (NCDs) programmes in low-income and middle-income countries.

via The Lancet by Mike Moore on 7/27/12
Sleep disorders are a common problem in primary health care, even among otherwise healthy individuals. Insomnia is associated with an increased risk of mental and physical illness, and results in decreased work productivity as well as reduced quality of life. Although sleep disorders can be managed in the short term with hypnotic and sedative medications, this approach is generally not appropriate for chronic sleep disorders due to the development of tolerance to the medications and potential dependence.

via The Lancet by Beryl A Koblin, Hong-Van Tieu, Victoria Frye on 7/27/12
The devastating effect of the HIV epidemic in Canada, the UK, and the USA is nowhere more evident than in men who have sex with men (MSM), and, particularly, in young black MSM. Distressing—but not well recognised—is that these ethnic disparities were present in the USA as early as 1984–89. Similar patterns were present throughout the 1990s and remain today. contributing to the classic pattern of a growing social disparity with preferential uptake of interventions in more powerful social groups.

via The Lancet by Jack Killen, Mark Harrington, Anthony S Fauci on 7/27/12
Men who have sex with men (MSM) have been at the centre of the battle against HIV/AIDS since the disease was first reported. Scientific perspectives on the epidemic in MSM are summarised elsewhere in The Lancet; more personal perspectives are the subjects of countless historical, biographical, and artistic works. We focus here on several contributions some of these men and their advocates have made collectively as researchers, health-care providers, government officials, journalists, and activists to the development of highly active antiretroviral therapy (HAART).

via The Lancet by Paul Semugoma, Steave Nemande, Stefan D Baral on 7/27/12
Homosexuals are “worse than pigs and dogs” asserted one former African President. Anti-gay rhetoric is the norm in countries across Africa, but this sentiment is dangerous and anachronistic. We discuss three ironies inherent in African homophobia, and their consequences not only for increasing risk of HIV/AIDS in men who have sex with men (MSM) but also for threatening people's health in Africa more generally.

via The Lancet by Michael Kyomya, Katherine W Todyrs, Joseph J Amon on 7/27/12
Although laws against sodomy violate international law and have myriad negative health effects, including impeded access to HIV prevention and treatment, about 80 countries criminalise consensual sex between adult men. The effect of these laws on the health of prisoners in sub-Saharan Africa has been little examined. Drawing on our research with prisoners and prison officials in Zambian and Ugandan prisons, and with prison medical directors in ten east and southern African countries (Burundi, Kenya, Malawi, Mauritius, South Africa, Swaziland, Uganda, Tanzania, Zambia, and Zimbabwe), we discuss here the effect of sodomy laws on HIV prevention and new directions for effective, rights-respecting HIV prevention programmes in prisons.

via The Lancet by Pamela Das, Richard Horton on 7/27/12
As the HIV epidemic enters its fourth decade, HIV transmission in several parts of the world shows no sign of abating—for example, in sub-Saharan Africa an estimated 1·9 million people became newly infected in 2010. Certain affected populations in the epidemic are more marginalised than others, notably gay men and other men who have sex with men. A biologically heightened vulnerability to HIV and the limited uptake and use of barrier methods, especially among younger cohorts of men who have sex with men, fuelled by stigma and in some parts of the world criminalisation, makes addressing the issue of HIV/AIDS in men who have sex with men complex, as this Lancet Series shows.

via The Lancet by The Lancet on 7/27/12
With two-thirds of the national adult population and more than a third of children and adolescents defined as overweight or obese, the US Food and Drug Administration (FDA) has been under mounting pressure to approve new weight-loss drugs. On July 17, the second new anti-obesity pill, extended-release phentermine and topiramate, received market approval on the heels of lorcaserin (approved on June 27). It has been 13 years since the last approval of long-term weight-loss drug orlistat. Safety concerns or lack of efficacy have doomed past applications.

via The Lancet by Peter Howitt, Ara Darzi, Guang-Zhong Yang, Hutan Ashrafian, Rifat Atun, James Barlow, Alex Blakemore, Anthony MJ Bull, Josip Car, Lesong Conteh, Graham S Cooke, Nathan Ford, Simon AJ Gregson, Karen Kerr, Dominic King, Myutan Kulendran, Robert A Malkin, Azeem Majeed, Stephen Matlin, Robert Merrifield, Hugh A Penfold, Steven D Reid, Peter C Smith, Molly M Stevens, Michael R Templeton, Charles Vincent, Elizabeth Wilson on 8/3/12

via The Lancet by Matthew DeCamp on 8/3/12
The Lancet's April 28 Editorial calls attention to the UK General Medical Council's (GMC's) draft guidance, Doctors’ use of social media. Calling the guidelines “not dissimilar” to other available guidance potentially understates how the GMC's guidance improves on its predecessors yet leaves crucial areas unaddressed.

via The Lancet by The Lancet on 8/3/12
No health without mental health, the UK Government's strategy for mental health in England was launched in February, 2011. On July 24 this year, the implementation framework designed to translate the government's vision into action was published. Rather than provide directions for clinicians and commissioners, the framework merely paints a more granular picture of how the strategy might be applied. Thus, 17 months on from the launch, the programme remains aspirational and incomplete. The delay and vagueness surrounding implementation, coupled with an absence of outcomes that can be evaluated, suggest a vision designed for political rather than clinical benefit.

via The Lancet by The Lancet on 8/3/12
“How good is a cure if only ten people can have it…or we haven't got the money to train doctors to use it properly?” So asks Nadia Fall, director of a new production of The Doctor's Dilemma, which revolves around rationing for a new treatment for tuberculosis. Access to beneficial health technology, including essential medicines and medical devices, for those most in need is a theme explored in this week's issue in The Lancet and Imperial College London's Commission on technologies for global health.

via The Lancet by Tom Kindlon on 8/10/12
Three of the four thresholds used by Sanne Nijhof and colleagues (April 14, p 1412) for their post-hoc definition of recovery from chronic fatigue syndrome are virtually the same as the entry criteria. For example, 40 or more on the fatigue severity subscale of the checklist individual strength 20 (CIS-20) was equivalent to “severe fatigue” at baseline, yet once a participant scored less than 40 (the mean +2 SDs for a healthy population) they could be counted as recovered! The face validity of their other post-hoc recovery definition, listed in the appendix, seems stronger, but it gives a much lower figure for recovery of 36% (rather than 63%).

via The Lancet by Bill Bynum on 8/10/12
The medical profession has always been conservative. Many individual doctors have broken rank and espoused advanced social or political causes, but they have always been the exceptions, not the rule. Most doctors, needing to earn a living in the medical marketplace, have spoken and behaved in ways that would assure their patients that they were in safe hands.

via The Lancet by Rob Hyde on 8/10/12
A recent ruling by Germany's Supreme Court has caused a public storm over the ethical conduct of doctors and drug companies in the country. Rob Hyde reports from Hamburg.

via The Lancet by The Lancet on 8/10/12
“If you cross-examine a child of 7 or 8 on his day's doings (especially when he wants to go to sleep) he will contradict himself very satisfactorily. If each contradiction be set down as a lie and retailed at breakfast, life is not easy. I have known a certain amount of bullying, but this was calculated torture.” Rudyard Kipling's description of abuse by his supposed caregivers in the 1870s makes for painful reading today. Physical maltreatment also took place; but it was the psychological maltreatment, the sense of rejection and isolation, that he would carry throughout his life, and which might have precipitated the “great darkness” of depression in his later years.

via (title unknown) by mchabot on 7/20/12
While bipolar disorder is something we all encounter in practice, views are mixed as to how best to diagnose and treat it.

via (title unknown) by mchabot on 7/20/12
Whether you work in a hospital or an office setting, you’ve probably seen many patients who come to you with a “history of bipolar disorder.” We’ve seen it, too, in multiple settings at an academic medical center. Is this a new epidemic? Or a redefinition of what it means to be “bipolar”?

via (title unknown) by mchabot on 7/20/12
How should we diagnose bipolar disorder? It isn’t always easy and current bipolar screening tools are problematic for a number of reasons.

via The British Journal of Psychiatry current issue by Mitchell, A. J., Meader, N., Bird, V., Rizzo, M. on 8/1/12
Clinicians have considerable difficulty identifying and helping those people with alcohol problems but no previous study has looked at this systematically.
To determine clinicians’ ability to routinely identify broadly defined alcohol problems.
Data were extracted and rated by two authors, according to PRISMA standard and QUADAS criteria. Studies that examined the diagnostic accuracy of clinicians’ opinion regarding the presence of alcohol problems as well as their written notation were evaluated.
A comprehensive search identified 48 studies that looked at the routine ability of clinicians to identify alcohol problems (12 in primary care, 31 in general hospitals and 5 in psychiatric settings). A total of 39 examined alcohol use disorder, 5 alcohol dependence and 4 intoxication. We separated studies into those using self-report and those using interview. The diagnostic sensitivity of primary care physicians (general practitioners) in the identification of alcohol use disorder was 41.7% (95% CI 23.0–61.7) but alcohol problems were recorded correctly in only 27.3% (95% CI 16.9–39.1) of primary care records. Hospital staff identified 52.4% (95% CI 35.9–68.7) of cases and made correct notations in 37.2% (95% CI 28.4–46.4) of case notes. Mental health professionals were able to correctly identify alcohol use disorder in 54.7% (95% CI 16.8–89.6) of cases. There were limited data regarding alcohol dependency and intoxication. Hospital staff were able to detect 41.7% (95% CI 16.5–69.5) of people with alcohol dependency and 89.8% (95% CI 70.4–99.4) of those acutely intoxicated. Specificity data were sparse.
Clinicians may consider simple screening methods such as self-report tools rather than relying on unassisted clinical judgement but the added value of screening over and above clinical diagnosis remains unclear.

via The British Journal of Psychiatry current issue by Casey, P., Doherty, A. on 8/1/12
Adjustment disorder has been a recognised disorder for decades but has been the subject of little epidemiological research. Now researchers have identified the prevalence of adjustment disorder in primary care, and found general practitioner recognition very low but with high rates of antidepressant prescribing. Possible reasons for the seemingly low prevalence, recognition rate and inappropriate management include its recognition as a residual category in diagnostic instruments and poor delineation from other disorders or from normal stress responses. These problems could be rectified in ICD-11 and DSM-5 if changes according it full syndromal status, among others, were made. This would have an impact on future research.

Autism has been in the forefront of science and public concern because of reported increases in its prevalence. Changing diagnostic practice and improved identification explain some of this rise, but there may also be a true increase. Aetiological research needs to include environmental factors to understand the causes of autism.

via The British Journal of Psychiatry current issue by Bywater, T. J. on 8/1/12
Two out of three children diagnosed with conduct disorder will not outgrow it without treatment. It is costly to the individual in terms of negative life outcomes and to society in terms of increased health, social and education service use. Psychosocial interventions are effective in psychologically managing and preventing the onset of conduct disorder.

via The British Journal of Psychiatry current issue by Morrison, A. P., Hutton, P., Shiers, D., Turkington, D. on 8/1/12
Evidence regarding overestimation of the efficacy of antipsychotics and underestimation of their toxicity, as well as emerging data regarding alternative treatment options, suggests it may be time to introduce patient choice and reconsider whether everyone who meets the criteria for a schizophrenia spectrum diagnosis requires antipsychotics in order to recover.

The American Board of Psychiatry and Neurology (ABPN) is a nonprofit corporation that was founded in 1934. The mission of the ABPN is to develop and provide valid and reliable procedures for certification and maintenance of certification (MOC) in psychiatry and neurology by:

via The American Journal of Psychiatry Current Issue by Byne W, Bradley SJ, Coleman E, et al. on 7/31/12
At its September 2011 meeting, the Board of Trustees (BOT) of the American Psychiatric Association (APA) voted to approve as a Resource Document the report of the Task Force on Treatment of Gender Identity Disorder (GID). Both the diagnosis and treatment of GID are controversial as reflected in the professional literature as well as in popular discourse where they have recently garnered considerable attention. In contrast to the treatment of other DSM diagnoses where emphasis is on changing thoughts, feelings and behaviors, the treatment of GID from adolescence onward often emphasizes modification of the body. Although psychiatric diagnosis and treatment are inextricably linked, they are separate issues and the DSM does not evaluate and compare the benefits and risks of alternative treatments. As the DSM-V workgroups were deliberating, the BOT, therefore, formed a task force to address concerns that go beyond those in the purview of the DSM-V work group addressing GID. The Task Force was charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to present a report to the BOT that would include an opinion as to whether or not sufficient credible literature exists for the APA to take the next step and develop treatment recommendations. Separate sections of the report assess the treatment literature in children, adolescents, adults, and individuals of any age with disorders of sex development (DSDs, aka intersex conditions; DSM-IV criterion C excludes individuals with DSDs from the diagnosis of GID. If they meet other criteria, they receive the diagnosis of GID Not Otherwise Specified. The current DSM-5 proposal recommends replacing GID with Gender Dysphoria and designating two subtypes, without and with a DSD.).

The following books are presented here as a service to our readership to alert them of new titles and as a courtesy to those who have sent copies of these books to the Journal office.

Jerome Frank was a towering figure in American psychiatry. Sadly, I doubt if his work is well-known by many in our profession. This carefully edited volume should fill that knowledge gap. The book is not a Festschrift, but a primer on common elements in psychotherapy, with a focus on the concept of demoralization. Its two editors have done a masterful job of carefully integrating the chapters in a sequential manner so that the book is a joy to read but also so that each chapter can stand alone.

via The American Journal of Psychiatry Current Issue by Nussbaum AM. on 7/31/12
In hierarchies of evidence-based medicine, expert opinion is portrayed as the least rigorous form of evidence, as the academic equivalent of bread in old food pyramids, i.e., reasonably nutritious, but not as potent as the randomized controlled trials and meta-analyses that are the equivalent of leafy green vegetables. Yet expert opinion is also portrayed, like bread in the food pyramid, as the foundation of evidence-based medicine, and thus the question becomes: On what sort of bread and what sort of expert opinion will you dine?

Interpersonal psychotherapy (IPT) was officially described and “codified” in the 1970s and 1980s with the publication of what are now classic studies and a foundational book (+1++3). Through decades of research, IPT has since been elevated to the anointed ranks of evidence-supported or evidence-based treatments. Therapists practicing IPT attend primarily to here-and-now issues, such as recent losses, interpersonal conflicts, role transitions (e.g., empty nesting, divorce, retirement), and interpersonal deficits (personality and communication difficulties). IPT fully respects biological, psychodynamic, and cognitive and behavioral influences and strategies. Featured techniques include education, exploration, interpretation, emotional ventilation, goal setting, and problem solving. Focusing on the psychological spaces in which most patients actually experience their problems, honoring and emphasizing the importance of the common and universal factors accounting for much of the favorable outcomes of psychotherapy, and fitting into an overall brief therapy time frame that many patients can actually accommodate, from my perspective, make IPT one of the most practical, holistic, and effective real-world psychotherapies.

via The American Journal of Psychiatry Current Issue by Perry J, Bond M. on 8/8/12
Research suggests that defense mechanisms may underlie other aspects of functioning and psychiatric symptoms. The authors examined whether defenses change in accordance with the hierarchy of defense adaptation during long-term dynamic psychotherapy and whether such change is associated with long-term outcomes on other measures.
Twenty-one adults with depressive, anxiety, and/or personality disorders entered long-term dynamic psychotherapy (mean=248 weeks) and subsequent follow-along (mean duration, 5.1 years). Measures of functioning and symptoms were gathered in periodic follow-along interviews, external to the therapy. A median of eight psychotherapy sessions over 2.5 years for each participant were rated using the Defense Mechanism Rating Scales quantitative method.
Overall, the lowest (action) and highest (high adaptive) defense levels in the hierarchy of defenses improved significantly, as did overall defensive functioning (median effect size=0.71, 95% CI=0.01–1.83). Overall defensive functioning still remained below the healthy-neurotic range. A higher number of axis I disorders and childhood histories of sexual abuse and witnessing violence were associated with a slower rate of improvement in defenses. Change in defenses within therapy by 2.5 years was highly associated with significant levels of change at 5 years in external measures of both functioning (rs=0.60) and symptoms (rs=0.58), controlling for initial levels.
Change in defensive functioning in long-term psychotherapy largely follows the hierarchy of defense adaptation. The relationship to long-term improvement in outcomes suggests that defenses be considered candidates for mediating improvement in functioning and symptoms.

via The American Journal of Psychiatry Current Issue by Baram TZ, Davis EP, Obenaus A, et al. on 8/8/12
Maternal sensory signals in early life play a crucial role in programming the structure and function of the developing brain, promoting vulnerability or resilience to emotional and cognitive disorders. In rodent models of early-life stress, fragmentation and unpredictability of maternally derived sensory signals provoke persistent cognitive and emotional dysfunction in offspring. Similar variability and inconsistency of maternal signals during both gestation and early postnatal human life may influence development of emotional and cognitive functions, including those that underlie later depression and anxiety.

via Schizophrenia Bulletin - current issue by Henriksen, M. G., Parnas, J. on 7/26/12
Anomalies of self-experience (self-disorders) constitute crucial phenotypes of the schizophrenia spectrum. The following qualitative study demonstrates a variety of these core experiential anomalies. From a sample of 36 first-admitted patients, all of whom underwent a comprehensive psychiatric evaluation, including the EASE scale (Examination of Anomalous Self-Experience), 2 schizophrenia patients were selected for detailed psychopathological presentation and discussion. The vignettes provide prototypical examples of what has been termed self-disorders in schizophrenia, ie, pervasive and enduring (mainly) trait phenomena which constitute essential aspects of the spectrum.

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