CAM for your anxious patient: What the evidence says

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
Ervin Davis, 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
Richard M. Bloch, PhD, Professor and director of research, 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
Sy Atezaz Saeed, MD, Professor and chair, Department of psychiatric medicine, Brody School of Medicine at East Carolina University, Greenville, NC

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM. Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options, CAM options for anxiety disorders are fewer and have less evidence of efficacy.

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Hallucinations in children: Diagnostic and treatment strategies

Kanwar Ajit S. Sidhu, MD, Assistant professor, Department of behavior medicine and psychiatry, West Virginia University, Charleston, WV

T.O. Dickey III, MD, Associate professor and program director, Department of behavior medicine and psychiatry, West Virginia University, Charleston, WV

Hallucinations in children are of grave concern to parents and clinicians, but aren’t necessarily a symptom of mental illness. In adults, hallucinations usually are linked to serious psychopathology; however, in children they are not uncommon and may be part of normal development.

A hallucination is a false auditory, visual, gustatory, tactile, or olfactory perception not associated with real external stimuli. It must be differentiated from similar phenomenon such as illusions (misperception of actual stimuli), elaborate fantasies, imaginary companions, and eidetic images (visual images stored in memory).

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Re-envisioning psychosis: A new language for clinical practice

Demian Rose, MD, PhD, Assistant professor, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Barbara Stuart, PhD, Staff psychologist, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Kate Hardy, ClinPsychD, Postdoctoral fellow, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Rachel Loewy, PhD, Assistant professor, Department of psychiatry, University of California, San Francisco, San Francisco, CA

“I haven’t wanted to call it psychosis yet…”
“I’m not sure if this is psychosis or neurosis.”
“I wonder if there’s a psychotic process underneath all of this?”
“Psychotherapy won’t help psychosis.”

In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.

The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.

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Questions about psychotherapy

Henry A. Nasrallah, MD
Editor-in-Chief

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

• What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?

• Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?

• What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?

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Schizophrenia in older adults

Abhilash K. Desai, MD, FAPA, Associate professor, Director Center for Healthy Brain Aging, Department of neurology and psychiatry, Division of geriatric psychiatry, Associate professor, Department of internal medicine, Division of geriatric medicine, St. Louis University School of Medicine, St. Louis, MO

Mehrzad Seraji, MD, Fellow, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Maurice Redden, MD, Instructor, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Ramasubba Tatini, MD, Private practice, St. Louis, MO

The number of older adults (age ≥65) who developed schizophrenia before age 45 is expected to double in the next 2 decades; the 1-year prevalence of schizophrenia among older adults is approximately 0.6%. This article reviews how positive, negative, and cognitive symptoms and social functioning change over decades and discusses strategies for reducing the impact of long-term antipsychotic use on neurologic and physical health. Although some patients experience schizophrenia onset later in life, in this article we focus on older adults who developed the illness before age 45.

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Vaccine for cocaine addiction

Robert M. Anthenelli, MD, Current Psychiatry Section Editor for substance use disorders, is professor of psychiatry, psychology, and neuroscience, director of addiction sciences division and Tri-State Tobacco and Alcohol Research Center, University of Cincinnati College of Medicine, and director of Substance Dependence Program, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH.

Eugene Somoza, MD, PhD, Professor of clinical psychiatry, University of Cincinnati College of Medicine, and director of the Cincinnati Addiction Research Center, Cincinnati, OH.

Unlike opioid or alcohol abuse, for cocaine dependence there are no FDA-approved pharmacotherapies, which leaves psychosocial treatment as the standard of care for the estimated 1.6 million individuals in the United States who abuse cocaine. However, researchers are developing a novel way to help cocaine-dependent patients reduce their drug use. Therapy for addiction–cocaine addiction (TA-CD) is thought to curb cocaine use by engaging the body’s immune reaction and stopping cocaine molecules from reaching the brain, thereby reducing the drug’s pleasurable effects.

One researcher working on this vaccine, Eugene Somoza, MD, PhD—the principal investigator of the Ohio Valley Node of the National Institute on Drug Abuse clinical trials network of 16 universities and treatment programs—discusses with CurrentPsychiatry Section Editor Robert M. Anthenelli, MD, how TA-CD works and how it might be used in clinical practice.

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Integrating psychiatry with other medical specialties

Henry A. Nasrallah, MD
Editor-in-Chief

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur.

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