Therapeutic neuromodulation

Philip G. Janicak, MD, Professor, Department of Psychiatry, Rush University Medical Center, Chicago, IL

Sheila M. Dowd, PhD, Assistant Professor, Department of Psychiatry, Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL

Jeffrey T. Rado, MD, Assistant Professor, Department of Psychiatry and Medicine, Rush University Medical Center, Chicago, IL

Mary Jane Welch, DNP, APRN, BC, CIP, Assistant Professor, College of Nursing, Director, Human Subjects Protection, Rush University Medical Center, Chicago, IL

The brain is an electrochemical organ, and its activity can be modulated for therapeutic purposes by electrical, pharmacologic, or combined approaches. In general, neuromodulation induces electrical current in peripheral or central nervous tissue, which is accomplished by various techniques, including:

• electroconvulsive therapy (ECT)
• vagus nerve stimulation (VNS)
• transcranial magnetic stimulation (TMS)
• deep brain stimulation (DBS).

It is thought that therapeutic benefit occurs by regulating functional disturbances in relevant distributed neural circuits. Depending on the stimulation method, the frequencies chosen may excite or inhibit different or the same areas of the brain in varying patterns. Unlike medication, neuromodulation impacts the brain episodically, which may mitigate adaptation to the therapy’s beneficial effects and avoid systemic adverse effects.

Neuromodulation techniques are categorized based on their risk level as invasive or noninvasive and seizurogenic or nonseizurogenic. Although these and other approaches are being considered for various neuropsychiatric disorders, the most common application is for severe, treatment-resistant depression. Therefore, this article focuses on FDA-approved neuromodulation treatments for depression, with limited discussion of other indications.

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Parricide: Characteristics of sons and daughters who kill their parents

Sara G. West, MD, Assistant Professor of Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH

Mendel Feldsher, MD, Consulting Forensic Psychiatrist, Patton State Hospital, Patton, CA

Parricide—killing one’s parents—once was referred to as “the schizophrenic crime,” but is now recognized as being more complex. In the United States, parricides accounted for 2% of all homicides from 1976 to 1998, which is consistent with studies from France and the United Kingdom. Parricide’s scandalous nature has long attracted the public’s fascination.

This article primarily focuses on the interplay of the diagnostic and demographic factors seen in adults who kill their biological parents but briefly notes differences seen in juvenile perpetrators and those who kill their stepparents. Knowledge of these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents.

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Depression treatment for women with breast cancer

Prachi Agarwala, MD, Psychiatry Resident, PGY-V, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Michelle B. Riba, MD, MS, Clinical Professor, Department of Psychiatry, University of Michigan, Ann Arbor, MI

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients, and depression is associated with a higher relative risk of mortality in individuals with breast cancer. Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

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Are some nonpsychotic psychiatric disorders actually psychotic?

Henry A. Nasrallah, MD
Editor-in-Chief

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms, including major depressive disorder, obsessive-compulsive disorder, anxiety disorders, and others.

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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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