CAM for patients with depression

Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Richard M. Bloch, PhD, Professor and director of research, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Diana J. Antonacci, MD, Associate professor and director of residency training, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

C. Ervin Davis, III, PhD, Assistant professor, department of psychology, Adjunct assistant professor of psychiatry, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Crystal Manuel, MD, Assistant professor, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

Americans with depression turn to complementary and alternative medicine (CAM) more often than conventional psychotherapy or FDA-approved medication. In a nationally representative sample, 54% of respondents with self-reported “severe depression”—including two-thirds of those receiving conventional therapies—reported using CAM during the previous 12 months.

Unfortunately, popular acceptance of CAM for depression is disproportionate to the evidence base, which—although growing—remains limited. As a result, your patients may be self-medicating with poorly supported treatments that are unlikely to help them recover from depression.

In reviewing CAM treatments for depression, we found some with enough evidence of positive effect that we feel comfortable recommending them as evidence-based options. These promising, short-term treatments are supported by level 1a or 1b evidence and at least 1 study that demonstrates an ability to induce remission.

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Listen to Dr. Manuel discuss how to negotiate CAM use with patients

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STEPPS for patients with borderline personality disorder

Donald W. Black, MD, Professor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Nancee Blum, MSW, Adjunct instructor, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Don St. John, MA, PA-C, Physician assistant, Department of psychiatry, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA

Treatment of borderline personality disorder (BPD) often is viewed as challenging and the results so discouraging that some clinicians avoid referrals of BPD patients. Psychotherapy has been the treatment mainstay for decades, and supportive approaches are probably the most widely employed. Psychodynamic therapy often has been recommended.

This article introduces a new evidence-based group treatment program that we developed for BPD patients. Systems Training for Emotional Predictability and Problem Solving (STEPPS) is founded on the successes of better known psychoeducational models but is easier for practicing psychiatrists to implement.

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Does psychiatric practice make us wise?

Henry A. Nasrallah, MD
Editor-in-Chief

At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”

That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.

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Transcend dread: 8 ways to transform your care of ‘difficult’ patients

John Battaglia, MD

Medical director, Program of assertive community treatment, Clinical associate professor, Department of psychiatry, University of Wisconsin, Madison, WI

Although “the difficult patient” is not a diagnosis or specific clinical entity, clinicians universally struggle with such patients and have an immediate sense of shared experience when describing the phenomenon. In primary care, O’Dowd aptly described this type of patient as the “heartsink” patient, meaning the practitioner often feels exasperation, defeat, or dislike when he or she sees the patient’s name on the schedule.

This article discusses the literature on this topic and provides strategies for dealing with difficult patients in psychiatric practice.

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Listen to Dr. Battaglia explain the advantages of "plussing" your difficult patient

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Help your bipolar disorder patients remain employed

Charles L. Bowden, MD

Clinical professor of psychiatry and pharmacology, Nancy U. Karren Distinguished Chair of Psychiatry, The University of Texas Health Science Center at San Antonio

Bipolar disorder’s long-term course presents a therapeutic challenge when patients desire to remain employed, seek temporary or permanent disability status, or—most commonly—attempt to return to employment after a period of inability to work. As the experience of Mrs. S illustrates, previous capabilities that appear higher than the person’s present or recent work experience are a key issue to address in interpersonal therapy.

Evidence-based research is informative, but ultimately you must apply judgment and flexibility in setting and revising goals with the bipolar individual. Attention to the disorder’s core characteristics can help you equip patients for work that contributes to their pursuit of health.

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Dissociative identity disorder: Time to remove it from DSM-V?

Numan Gharaibeh, MD

Staff psychiatrist, Department of psychiatry, Danbury Hospital, Danbury, CT

Dr. Gharaibeh is a an attending psychiatrist on the inpatient unit at Danbury Hospital in Danbury, CT. He teaches psychiatric residents from New York Medical College during their rotation in Danbury Hospital and physician assistant students from Quinnipiac University, Hamden, CT.

What is it about dissociative identity disorder (DID) that makes it a polarizing diagnosis? Why does it split professionals into believers and nonbelievers, stirring up heated debates, high emotions, and fervor similar to what we see in religion?

The DID controversy is likely to continue beyond the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), slated for publication in 2012. Proponents and opponents claim to have the upper hand in arguments about the validity of the DID diagnosis and benefits vs harm of treatment. This article examines the logic of previous and new arguments.

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Paradigms shift rapidly in antipsychotic treatment

Henry A. Nasrallah, MD
Editor-in-Chief

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions, paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried. However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

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