Current Psychiatry Reviews - Volume 6, Issue 1, 2010

Expectancies are a class of psychological and neurobiological processes that may be responsible for part of the improvement observed with psychiatric treatments. Patients' expectations can substantially affect the results of clinical trials, and managing them is an important part of clinical care. This review describes the history of research on expectancy effects in Major Depressive Disorder (MDD), the relationship between expectancies and placebo effects, and what is currently known about the mechanisms of action of expectancy. Meta-analyses of antidepressant trials show that placebo response rates are high (typically ∼30%) and often larger than the difference in response rates between drug and placebo (typically ∼10%). Some of the response to placebo is due to natural history, but a growing literature suggests that much of the improvement on placebo treatment is due to active neurobiological processes related to expectancy. Several studies have shown that higher expectation of therapeutic improvement leads to greater improvement in psychiatric symptoms, particularly in MDD. New research on the mechanisms of action of expectancy is therefore a priority that could lead to improved interventions. This review discusses the evidence to date and methodological considerations in the design of new studies.

Until relatively recently meditation was considered an esoteric subject unrelated to mainstream medical or psychological therapies. Over the last few decades meditation has been studied in a non religious, therapeutic setting. We describe what meditation isand define it as “being in the moment”. We also define the different types of meditation, including both mindfulness based stress reduction and mindfulness based cognitive therapy, both of which have become standardised therapeutic interventions. We further describe evidence from meta-analyses and review articles of the beneficial effects of meditation on brain EEGs, the immune response, pain control, and anxiety and depression. Finally we discuss the potential of, and evidence for, its use in patients with sexual dysfunction.

A novel form of dynamic analysis of mental status is postulated based on the theoretical concept that human behavior possesses a dual nature, comparable to waves and particles. Just as with quantum physics, both must be taken into account to obtain an accurate description. Human biological rhythms are governed by wave-based forms, including 28-day, 25-hour and ultradian (90-minute) periods. This study describes the elements involved in behavioral cycles in relation to biogenic amines. Koestler's concept of the “holon,” meaning both whole and part, is employed here to depict the components of individual or group personalities. The individual or “particle” in this formation can be viewed as composed of several more elementary cognitive particles which represent the independence, integration, cooperation, and competition with a person's social world. The novel method proposed here could provide a new means of describing human behavior and classifying mental disorders in a dynamic context.

This paper reviews the problems of psychiatric assessment and the prediction of incapacity in the pilot population. It reviews the difficulty of providing evidence based standards and the interaction of intermittent stressors with performance as well as the difficulties of diagnosis and prediction in a population who may not fully disclose significant histories. Also reviewed are possible biases toward under-attribution of psychiatric causation in accidents and incidents. The significance and treatment of depression and substance abuse are reviewed and some general principles of the assessment of risk in relationship to the impact of psychiatric disturbance and the likelihood of pilots encountering a situation in which this will become significant are considered. The application of these principles to the problem of attention deficit disorders is demonstrated and discussed.

Severe major depressive disorder (MDD) is associated with poorer response to treatment than milder forms of depression, but there is a lack of consensus about the optimal treatment approach. We conducted a qualitative review of the literature for clinical trials of severe MDD in adults (1975 - December 2008), to assess the effects of five treatment approaches: placebo, medication, psychotherapy, combined treatment, and medication augmentation. We found significant variability in treatment outcomes across studies of severe MDD, deriving largely from differences in study design and variability in study samples identified as “severely” depressed. Severely ill patients respond more poorly to placebo and psychotherapy than mildly or moderately depressed patients. Medication monotherapy is superior to psychotherapy alone in the treatment of severe MDD. Combination treatment with medication and psychotherapy shows greater utility in severe, rather than mild or moderate, MDD. Lithium is the best established augmenting agent for severe MDD, particularly in combination with a tricyclic antidepressant. This review indicates the best initial clinical approach to treating severe major depressive disorder is through a combination of medication monotherapy and structured psychotherapy. Future trials in severely ill patients should more fully characterize the clinical and biological aspects of the enrolled patients.

Obsessive-compulsive disorder (OCD), a common complex psychiatric illness with a 2% lifetime prevalence rate is highlighted by World Health Organization (WHO) as one of the top 5 disabling illnesses in the world. Its treatment was the focus of formal guidance from National Institute for Clinical Excellence (NICE) in 2005. Despite the increased focus on treatment of OCD, it is an area that is often misunderstood and undertreated. It is particularly tragic as OCD is surprisingly easy to treat and amenable to both psychological and psychopharmacological treatment. This review examines the important changes that have taken place in the psychological and psychopharmacological treatments for OCD in recent years. How these treatments may be delivered using the framework of NICE guidance will also be discussed. Finally the review will examine current experimental treatments and possible future developments in the management of patients.

Purpose: Mood and anxiety disorders are among the most common behavioral sequelae of breast cancer as well as fatigue, sleep disturbance, and cognitive impairment. These symptoms cause serious disruption in patients' quality of life. In this review, we looked at the prevalence of depression and anxiety in breast cancer patients. The risk factors to develop mood and anxiety disorders in breast cancer, the effect of the different treatments against cancer on mood and the means to evaluate and treat mood and anxiety disorders in breast cancer patients were also analysed. Design: We searched on the pubmed database for articles relating to mood and anxiety disorders and breast cancer. Then, we selected those which included a significant number of patients and used validated instruments. Most of the studies retained for analysis were published in the last 4 years. Results: Depression and anxiety are frequent in breast cancer and often undertreated. Several factors have been identified as predictor of them. We reported the results obtained by studies which have investigated the link between the treatment against cancer mood and anxiety disorders. Clinicians are well equiped to assess depression and anxiety in breast cancer population. However, the current tendency is to elaborate specific instruments. Symptoms of depression and anxiety are quite improved by medication and psychotherapy. Discussion: As the number of people with breast cancer will continue to increase over the time, efforts are needed to improve the care of these patients who are also affected by mood and anxiety disorders.

Until recently, Japan had been unique in having no specialized legal provision for mentally ill criminal offenders. After longterm debate, fresh legislation was passed at last in 2003 to deal with the offenders who committed a felony such as homicide, arson, robbery, rape, indecent assault and injury under insane conditions by which they were judged to be criminally irresponsible or to have diminished responsibility. This new law came into effect in mid 2005 as the Act for the Medical Treatment and Supervision of Insane Persons who Caused Serious Harm (often abbreviated as ‘Medical Treatment and Supervision Act’), which is to be reformed according to necessity in 2010. Until 1st of November 2008, this law had already been administered to 1,264 cases. Considering that this act has not yet been widely known abroad and thus it tends to evade criticism from international forensic psychiatric points of view, it appears timely to survey this act and related mental health care systems in Japan by which mentally ill patients with criminal conduct are treated. In this article, we review the present status of how to manage mentally ill offenders and violent psychiatric patients within the framework of Japanese law system, focusing on clinical and practical problems experienced by general psychiatrists engaged in treatment of these patients. Our hope is that this review presents a clue to gather international peer critical opinions leading to reconsideration and revision of the present systems, resulting in contribution to better treatment of all patients with psychiatric disorders.