Archive for the ‘American Psychiatric Association’ category

In The Moment

May 20th, 2011

I just attended the APA meeting in Honolulu. One day I got in a little pool time. Sitting in an idyllic Hawaiian setting, on a perfect day, I glanced around and noticed about half the people at the pool were talking on cell phones. I pass people on the street walking with their children but gossiping with friends on the phone. Pet owners often miss out on the joy of play with their furry companion in favor of seemingly trivial chatter. Climbing Diamondhead outside of Honolulu, I reached the top, marveled at the site (and caught my breath), and had to step around distracted people on their cell phones. Let’s not even touch the subject of distracted driving.

I love many of the advances modern technology has brought us—including the ability to keep in touch across miles, to reach out to loved ones through satellite communications and so many electronic formats. But moments of intimacy, awe, play, solitude, and quiet are vital to our souls. Let’s not drown them out with noise.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry

 

 

 

 

 

 

Press Reactions to the MDD Treatment Guideline

October 6th, 2010

The 3rd APA Treatment Guideline for Major Depressive Disorder is about to be published. Press releases went out late last week. I’m the only person who participated in the writing of all three iterations, and I chaired the work group that wrote the most recent one.

We began in 2006. I was then in Tucson and have since migrated to Madison, WI, and then to Central Pennsylvania and Penn State. It’s been a long four years. First came the scholarship, sifting through myriad papers, studies, and data. Many, many calls and emails. Then came over a thousand comments from colleagues in practice, scientists, and medical directors of companies that made depression treatments. All had to be responded to in multiple drafts and what felt like endless rewriting. Finally, the complex APA hierarchy had to read, discuss, consider, and vote. We’re finally done.

I was surprised  by some of the press reaction. ECT was a small part of a very long document, which details a growing panoply of options for treating depressed people: from diet and exercise through therapy and medication and on to various ways to stimulate the brain electrically or magnetically. But ECT, with its echoes of “Cuckoo’s Nest,” evokes emotion and, I suppose, captures readers’ attention.

A blogger for a major news weekly turned the Guideline into a battle between psychiatrists and psychologists. I learned that we hate each other. (Really?)

When Marty Keller and others looked at depression treatment in the early 1980s, they learned that only 20% to 25% of depressed people get minimally adequate treatment. NIMH and various advocacy groups launched campaigns to educate doctors and the public. Managed care was graded by accrediting agencies on how well they diagnosed and treated depression. Now, 30 years later, the percentage of depressed people who receive minimally adequate treatment remains more or less the same.

But what titillates the press is that “shock treatment” remains among our treatments. And that sometimes psychiatrists and psychologists disagree or have guild arguments. To me that’s sad. We need better press agents for improving mental health access and care.

DSM

September 20th, 2010

Most psychiatrists are aware of the turmoil swirling around the next iteration of the venerable DSM: DSM-V. The process and many proposed changes are under scrutiny and sometimes attack. I have two lower-key concerns, which apply to DSM-IV and probably will be relevant to the next generation.

The shift from DSM-II to DSM-III gave us the current multi-axial format, based largely on the systematic descriptive approach used  at Washington University in St. Louis. DSM-III brought superior reliability: independent assessors were more likely to agree on a diagnosis.

But many senior clinicians have lamented the “checklist interview” this approach has fostered. We observe residents rush from question to question, dutifully recording the spoken answer, without taking in the nuance, tone of voice, facial expression, and body posture of the person sitting opposite. The follow-up question that a patient may be begging to have asked goes unaddressed. Surely, we need to collect and record data. But we can do so without losing the art of good interviewing. Psychiatrists still need to “listen with the third ear.”

And if reliability with DSM-III and IV are so high, how do we account for patients with long strings of incompatible diagnoses? Sit at the door on any psychiatric unit, and those conflicting diagnoses in patients’ histories are the rule, not the exception. In my experience, they reflect the sloppy use of the DSM rules. Sure, you and I are likely to agree on a diagnosis in most axes—provided that we both play by the same rules.  Like it or not, the DSM is our dictionary, the common language that allows communications. And like any language, it requires precise use per agreed-upon definitions. When we do less, any “signal” gets lost in the “noise.”

MDD Guidelines

June 15th, 2010

Whew. This wasn’t easy. But it was necessary. And I hope useful for years to come.

A work group of the American Psychiatric Association just finished a 4-year gargantuan effort to revise and update the Major Depressive Disorder Treatment Guideline. And the APA has now formally approved the document.

I chaired the work group, made up of esteemed scholars, scientists and clinicians who gave generously of their time and talents.  Together we considered how much had changed since the second version of the guideline came out in 2000.

  • New medications have been studied in short- and long-term trials.
  • Drugs have been approved as adjuncts.
  • New forms of psychotherapy have been created and studied.
  • Nutritional supplements and exercise have been proposed and studied.
  • New stimulation interventions are available.

The work group looked carefully at each, and debated the pros and cons on their scientific merits. Some of the new treatments met the test for recommendation by this work group, and subsequently by the APA.

While there are many effective treatments, both new and old, as a whole, available options leave much to be desired.  Even after repeated treatments with a variety of medications and methodology, as many as one third of patients will remain symptomatic. There remains a tremendous need.

Given our current limitations, however, I am confident the new guidelines will help clinicians choose among a wide variety of approved treatments, from diet and exercise to brain stimulation. And our work must continue.