History of psychiatry

Antipsychotics in Perspective: Past, Present, and Future

For more than half a century, there has been controversy and conflict over using psychotropic medications ("psychotropics") as strategies to modulate behavior, enhance mood, and address cognitive issues for nursing home residents. The current situation reflects a long history of investigation, reports, discussions, government and professional activity, and other attempted improvement. Although attention has focused primarily on the use of antipsychotics, particularly to manage symptoms associated with dementia, there are much broader issues. The use of all psychotropics has arguably been challenging and inconsistent. Although antipsychotic use in nursing homes has been reduced substantially, many controversies and concerns remain, such as the continuing significant use of other psychotropics. It is tempting to conclude that efforts to reduce the use of these medications might have been deliberately stymied, and that more drastic-if not coercive-measures are needed to correct these issues. However, many other compelling considerations must be defined accurately and addressed. Further improvement in the current situation requires reconsidering some current beliefs and approaches. A pause and reopening of meaningful discussion is needed. This 3-part series (in this and the next 2 issues of The Senior Care Pharmacist) will examine the history of the issues (this month), various perspectives on the issues (part 2), and lessons and recommended approaches for the future (part 3).

Patient Perspective in Saudi Arabia: What Qualities Make a Good and Competent Psychiatrist?

Introduction The good qualities of a psychiatrist can vary when asking a psychiatrist, a resident, a student, or even a patient. The patient's perspective, however, is of utmost importance and can be extremely unique. Our study aims to visualize and analyze the perspective of outpatients of the psychiatric department at King Fahad Hospital University on what qualities make a good and competent psychiatrist. As psychiatric medicine depends a lot on the psychological aspect, it yields high importance on studying how patients perceive and see their doctors in different regions of the world. For this reason, we conducted our study in Al-Khobar, Kingdom of Saudi Arabia (KSA). Materials and methods A self-structured questionnaire named "What Qualities Make a Good and Competent Psychiatrist?" was developed and used to achieve the study objectives. It encompasses six sections: patients' personal data and demographics, patients' medical data, psychiatrists' personal traits, knowledge domain, social domain, and clinical setting domain. Results After data collection and analysis, our results showed the following. Patients did not have a generalized preference for personal traits or demographics; however, they preferred Saudi and Arabic-speaking physicians among others. Patients preferred their psychiatrists to be up to date with current research. The score per item is the lowest in the clinical domain, indicating that for the respondents, the clinical domain is the most important trait of a psychiatrist. Of the patients, 66.8% reported that appropriate grooming and clothing were crucial for a psychiatrist. Empathy and proper communication were also very important from the patients' points of view. Social and knowledge domains are also of extreme importance in our region. Discussion In our study, there seems to be no preference toward a psychiatrist's demographic traits with the exception of a Saudi nationality and being an Arabic speaker. The traits explored in this study are categorized into three domains: clinical setting domain, knowledge domain, and social domain. Of the three domains mentioned, the clinical setting domain was deemed the most important, followed by the social and knowledge domains. In a study conducted in Singapore, the social characteristics of the psychiatrist, which represented care and sympathy, were the main concern of patients. A study conducted in the UK showed that the participants were less concerned with the organizational social aspects of the medical processes than the clinical management components. Although the overall requirement for a knowledgeable, skilled, and socially competent psychiatrist and a proper clinical setting is sought by most psychiatric patients in different cultures and countries, there are also significant differences in the priorities of such characteristics. This emphasizes how every region has its standards for this occupation. Conclusion The results of this study suggest a variety of patients' and guardians' perspectives in different cultures with the clinical setting being an integral part of the psychiatrist's practice in Al-Khobar, KSA. The results showed that the clinical setting domain was the most critical domain, followed by social and knowledge domains. To improve patient experience and satisfaction, certain actions should be taken into consideration in our region.

The Reorganization of a Psychiatric Unit During COVID-19: A Reflection for Psychiatric Hospital Design

OBJECTIVE

The COVID-19 pandemic has impacted healthcare systems worldwide. Although this disease has primarily impacted general medicine intensive care units, other areas of healthcare including psychiatry were modified in response to corona measures to decrease the transmission of the disease. Reflecting on the modifications to the environment provides an opportunity to design psychiatric environments for future pandemics or other demands for healthcare.

BACKGROUND

The therapeutic environment of psychiatric wards was modified in Friesland, the Netherlands, in response to COVID-19. During this time, an interdisciplinary team met consistently to contribute to the preliminary design of a new psychiatric hospital.

METHODS

During the first 18 months of the pandemic, clinical reflections were made to describe the impact of COVID-19 on the psychiatric care environment. Architects have created a preliminary design of a new psychiatric hospital based on these reflections, monthly collaborative design discussions based on virtual mock-ups and evidence-based design based on theoretical concepts and research.

RESULTS AND CONCLUSIONS

This theoretical and reflective study describes how an inpatient psychiatric environment was restructured to manage infection during COVID-19. The therapeutic environment of the psychiatric ward and patient care changed drastically during COVID-19. The number of patients accessing care decreased, patient autonomy was restricted, and the function of designated behavioral support spaces changed to manage the risk of infection. However, these challenging times have provided an opportunity to reflect on theories and consider the design of new hospital environments that can be adapted in response to future pandemics or be restructured for different care functions.

Global publications on stigma between 1998-2018: A bibliometric analysis

OBJECTIVES

To describe the development process and structural relationships of scientific achievements on stigma over the past two decades and to provide insights for researchers and policy makers to drive policy decisions and identify future research needs.

METHODS

Quantitative analysis of publications was directly interpreted and graphed through Web of Science and ORIGIN 2017. The co-occurrence and collaboration analysis between authors, countries and keywords were conducted through VOSviewer. Keyword burst was detected through CiteSpace.

RESULTS

The retrieved 2,799 publications showed a trend of increasing annual publications between 1998 and 2018. The United States made the greatest contribution to global publications regarding stigma. Four keyword clusters indicating research hotspot were identified through the default clustering method in VOSviewer. Meta-analysis and internalized stigma were detected as keyword bursts in recent years.

CONCLUSIONS

The growth trend of publications indicated increased research interest in stigma, especially common stigma types, including HIV stigma and obesity stigma. Future research should focus on other types of stigma and should include more elaborate intervention programs, mechanism exploration, and research on internalized stigma. Scientific research on stigma requires an extensive collaborative endeavor, both domestically and internationally, among diverse researchers, institutions, and countries.

Trainee experience in diagnosis and management of personality disorders

The diagnosis and management of personality disorders continues to evolve and develop alongside psychiatry internationally, however, not always in a linear fashion. Trainees working in a variety of clinical areas have regular exposure to personality disorder presentations. Psychiatry training bodies continue to adapt their training structure and curriculum, however, there seems to be a lack of sufficient emphasis with regards this area. We are now embarking on a new diagnostic system for personality disorders; this may impact on our clinical practice and perspective of these patients. The role of psychiatrists in diagnosing and managing personality disorders can be unclear at times and may benefit from on-going reflection and standardization.

Applying intervention mapping approach to a program for early intervention in first-episode mental crisis of a psychotic type

The holotropic mind perspective, an integral part of the framework of transpersonal psychology, has been considered a revolutionary approach to a certain spectrum of experiences in Non-ordinary states of consciousness (NOSC) which conventional approaches tend to treat indiscriminately as pathological processes, because PHM recognizes in these experiences their healing and evolutionary potential. This article describes the needs assessment, implementation, and evaluation of an experiential and educational program on the holotropic mind perspective and its praxis, Holotropic Breathwork® (HB), with students and professionals from the Group for Early Intervention in First-Episode Mental Crisis of a Psychotic Type of the University of Brasilia. The intervention aimed to establish change goals and objectives that would promote the adoption of the holotropic mind perspective's elements, such as a framework to broaden and strengthen mental health programs that assist people experiencing NOSC. The stages developed, inspired by the Intervention Mapping protocol, included a needs assessment; elaboration of change objective matrices; selection and description of methods based on theory and their applications; conception, planning, and implementation of the intervention; and results evaluation. Participants reported that the intervention allowed the expansion of their theoretical-conceptual and technical frameworks, giving them a less pathologizing understanding of and approach to NOSC and allowing them to perceive and manage such states, not as indiscriminately pathological expressions, but as phenomena inherent to the human condition that can be accepted and cared for without the exclusionary and exhaustive bias of mental disorders. Limitations and practical implications are discussed.

Crossing Death Valley: Bringing Neurotechnology to Psychiatric Clinics in Alberta, Canada

Depression is a major public health problem, with a lifetime and 12-month prevalence estimated at 18 and 6% of adults. Depression is costly in terms of treatment and lost productivity and is the main burden of mental illness across the globe. Existing pharmacological and psychological treatments for depression result in clinically meaningful improvements in <60% of patients. An emerging treatment approach is non-invasive brain stimulation of depression-related brain targets through transcranial magnetic stimulation (TMS). In this perspective, we detail our efforts on bringing TMS to clinical populations in Alberta by utilizing a novel organizational structure that bridges the gap between academia and the health care system. The Addictions and Mental Health Strategic Clinical Network worked with stakeholders to (1) examine the evidence, (2) develop clinical tools for patient selection and protocol application, (3) create overall implementation and evaluation plans to aid in further scale and spread, and even (4) fund the purchase and deployment of devices. Through this work, five publicly supported clinics now exist in Alberta.

Stanley Cobb, the Rockefeller Foundation and the evolution of American psychiatry

Stanley Cobb founded the Harvard Departments of Neurology (1925) and Psychiatry (1934) with Rockefeller Foundation funding. Cobb was an important transitional figure in both neurology and psychiatry. He and his friend Alan Gregg were the most visible parts of the Rockefeller Foundation psychiatry project, which prepared American psychiatry for the rapid growth of psychiatric research after World War II. Edward Shorter called him the founder of American biological psychiatry, but this misunderstands Cobb and the Hegelian evolution of twentieth-century American psychiatry. I review the major role of the Rockefeller Foundation in the evolution of American academic psychiatry and the disappearance of Cobb's teaching and that of his mentor Adolf Meyer, a founding father of American academic psychiatry.

Psychopharmacology: From serendipitous discoveries to rationale design, but what next?

Psychopharmacology really developed as a discipline from the mid-20th century with the discovery of a number of new classes of psychoactive drugs which could modify behaviour. These drugs were discovered as a consequence of clinical observations of patients, often being treated for other conditions. These serendipitous discoveries were the start of an era of drug development which has led to the antidepressants, antipsychotics, anxiolytics and mood stabilisers used today. Subsequent research focused on understanding why these drugs were effective, and used this information to develop a second generation of drugs that were more selective for their therapeutic targets, and therefore had reduced side effects and improved safety and tolerability. After a period of decline in new discoveries and withdrawal of the majority of the major pharmaceutical companies from active development programmes in psychiatry, new avenues are emerging fuelling renewed interest in this area.

Do the Trajectories of Bipolar Disorder and Schizophrenia Follow a Universal Staging Model?

OBJECTIVE

The purpose of this study is to address the question of whether a universal staging model of severe psychiatric disorders is a viable direction for future research by examining the extant literature.

METHOD

A narrative review was conducted of the relevant historical, conceptual, and empirical literature pertaining to the clinical trajectory of bipolar disorder and schizophrenia and issues relevant to staging.

RESULTS

There is substantive evidence that classic recurrent bipolar disorder is separable from schizophrenia on the basis of family history, developmental and clinical course, treatment response, and neurobiological findings. However, because of the intrinsic heterogeneity of diagnostic categories that has been amplified by recent changes in psychiatric taxonomy, key distinctions between the groups have become obfuscated. While mapping risk and illness markers to emerging psychopathology is a logical approach and may be of value for some psychiatric disorders and/or their clinical subtypes, robust evidence supporting identifiable stages per se is still lacking. Presently, even rudimentary stages such as prodromes cannot be meaningfully applied across different disorders and no commonalities can be found for the basis of universal staging.

CONCLUSIONS

Advances in the prediction of risk, accurate early illness detection, and tailored intervention will require mapping biomarkers and other risk indicators to reliable clinical phases of illness progression. Given the capricious nature of mood and psychotic disorders, this task is likely to yield success only if conducted in narrowly defined subgroups of individuals at high risk for specific illnesses. This approach is diametrically opposite to that being promulgated by proponents of a universal staging model.

Genome wide association studies (GWAS) and copy number variation (CNV) studies of the major psychoses: what have we learnt?

Schizophrenia (SZ) and bipolar disorder (BPD) have high heritabilities and are clinically and genetically complex. Genome wide association studies (GWAS) and studies of copy number variations (CNV) in SZ and BPD have allowed probing of their underlying genetic risks. In this systematic review, we assess extant genetic signals from published GWAS and CNV studies of SZ and BPD up till March 2011. Risk genes associated with SZ at genome wide significance level (p value<7.2 × 10(-8)) include zinc finger binding protein 804A (ZNF804A), major histocompatibility (MHC) region on chromosome 6, neurogranin (NRGN) and transcription factor 4 (TCF4). Risk genes associated with BPD include ankyrin 3, node of Ranvier (ANK3), calcium channel, voltage dependent, L type, alpha 1C subunit (CACNA1C), diacylglycerol kinase eta (DGKH), gene locus on chromosome 16p12, and polybromo-1 (PBRM1) and very recently neurocan gene (NCAN). Possible common genes underlying psychosis include ZNF804A, CACNA1C, NRGN and PBRM1. The CNV studies suggest that whilst CNVs are found in both SZ and BPD, the large deletions and duplications are more likely found in SZ rather than BPD. The validation of any genetic signal is likely confounded by genetic and phenotypic heterogeneities which are influenced by epistatic, epigenetic and gene-environment interactions. There is a pressing need to better integrate the multiple research platforms including systems biology computational models, genomics, cross disorder phenotyping studies, transcriptomics, proteomics, metabolomics, neuroimaging and clinical correlations in order to get us closer to a more enlightened understanding of the genetic and biological basis underlying these potentially crippling conditions.