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Issue 100, Aug 2020
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Schizophrenia

The treatment of schizophrenia a century ago and in the present (2020)

The period of 1920

During this time frame, psychotic disorders were associated with demonic spirits and the devil. These disorders instilled fear in those around them. These individuals were thought of as someone who "has been maddened by the sin of gods, or been robbed of sense by the Rakshas”.The stereotypes of madness were often synonymous with the symptoms of schizophrenia.

Ancient Egyptian and Chinese medicine suggested the heart as being the central player, controlling the mind and spirit. Hence it was inferred that symptoms of insanity and madness were associated with afflictions of the heart. Emil Kraepelin wrote a paper "The Influence of Acute Illness in the Causation of Mental Disorders."  He was working on the classification of mental illness around that time frame. While Kraepelin called these patients as having “Dementia Praecox”, it was Eugene Bleuler who in 1908 coined the term schizophrenia. Bleuler stated that dementia praecox was neither associated with dementia or precociousness and emphasized the splitting of psychic functioning as an essential feature of schizophrenia.

Hence with this backdrop treatments in the early 20th century were crude and lacked evidence. These treatments often involved gas therapy and injection of sulphur or oils to induce fever. At this point, even prefrontal leukotomy or insulin coma therapy were not in use. These approaches came in to use after 1935.

In summary, there were no well-established treatments 100 years ago and patients were housed in asylums and had agricultural duties.

Owen R. Schizophrenia-From devilry to disease. Res Medica 2014;22: 126-132

Fast forward 100 years later the year 2020

Now there are multiple hypotheses as to the cause of schizophrenia. There have been twin and family studies suggesting heritable risk factors account for 80% of the risk of this psychiatric disorder in a population. Now we think on the lines of environmental factors such as obstetric complications, immune system-related factors, and synaptic plasticity and function. These factors are thought to have an interaction with genetic risks to increase the likelihood of schizophrenia.

Sophisticated MRI studies have revealed lower gray matter volumes. Studies reveal there is increased gray matter loss over time in the prefrontal and parahippocampal brain regions amongst those with psychosis. Immunological markers (related to cytokines) have been associated with the rate of gray matter loss. Theories have developed around a lack of coordination between various brain regions such as the prefrontal cortex, temporal cortex, hippocampus, thalamus, and cerebellum. The concept of cognitive dysmetria has been proposed. Animal models using rats, mice, and primates have been developed for the study of this disorder.

There have been various diagnostic classifications of schizophrenia into subtypes (paranoid, undifferentiated, disorganized type) which have been abandoned now in DSM-5 due to lack of consistency, reliability, and to simplify the diagnosis.

Neurochemical models such as the theory that psychosis is related to excessive dopamine activity are established. This theory suggests that medications blocking the D2 receptor cause downstream changes leading to clinical response. These medications, however, block dopamine activity in the basal ganglia leading to neuroleptic-induced parkinsonism. Similarly, effects on the tuberoinfundibular system lead to elevations in prolactin levels and related effects. More recently it is known that dopamine interacts with glutamate and γ-aminobutyric acid (GABA) affecting the functioning of microcircuits modulating the excitatory and inhibitory interneurons in cortical circuits. These neurotransmitters are being targeted more recently for the development of therapeutic agents. We also recognize now that the use of cannabis can precipitate schizophrenia in at-risk individuals.

It is well established that antipsychotic medications are effective in treating psychotic symptoms. We have a wide variety of antipsychotic drugs in 2020. This ranges from chlorpromazine the first antipsychotic available (not much used) to D3/D2 receptor partial agonists (cariprazine). Additionally, we also have clozapine which works for treatment-refractory schizophrenia. This drug also has an FDA indication for suicidality. The side-effects of the conventional antipsychotics include movement disorders such as extrapyramidal side-effects and TD while the atypical antipsychotics predominantly have weight gain and metabolic issues. There is a newer group of medications such as cariprazine, lurasidone, and lumateparone that have minimal if any weight gain.

The use of cognitive-behavioral therapy in schizophrenia has also helped manage this disease especially those who are partially responsive to medications for schizophrenia. Multiple other approaches are available such as family-based services, skills training, supportive employment. There is also the availability of IQ testing which can be helpful.

Long-acting injectable (LAI) antipsychotics have been developed and there are many to choose from in the year 2020. The dosing interval is variable for some of these medications (1-3 months). Side-effects such as tardive dyskinesia now also have FDA approved treatment choices such as valbenazine and deutetrabenazine.

Marder SR and Cannon TD. N Engl J Med 2019;381: 1753-1761

Clinical Commentary

There has been a dramatic change in the therapeutic approaches to treating schizophrenia with a wide variety of antipsychotic agents and psychosocial treatments. We also have the capability of monitoring for side-effects of these medications. We also can find out about drug-drug interactions and guide the physicians. We now aim for functional integration into society with stigma much reduced, unlike these patients being shunned 100 years ago. The future is a lot brighter now for this group of patients. We have been better able to separate individuals with severe mood disorders better now using a multitude of approaches. We still have not been able to detect a cause for this illness. Brain imaging and other studies have not been diagnostic either. We are however better able to give guidance for prognosis. Importantly the majority of our patients now live in the community. The mainstay in management is still an accurate longitudinal history, getting collateral information, and the use of antipsychotic agents.

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Major Depression

The treatment of major depression a century ago and in the present (2020)

The period 1920

The term depression was derived from the Latin verb deprimere “to press down”. Since the 14th century, “to depress” indicated to bring down in spirits. Melancholia was the preexisting term which was subsequently changed by Emil Kraepelin to depressive states. Henry Maudsley proposed the category of affective disorders.

Kraepelin had unified all types of mood disorders under the category of manic-depressive insanity. In 1920 Kurt Schneider coined the terms endogenous depression and reactive depression. There was a debate about the various diagnostic classifications at that time resulting in some (Edward Mapother1926) refuting these classifications. In the United Kingdom, the unitarian view became popular while the binary view was held in the US influenced by Adolf Meyer and Sigmund Freud. The state of melancholia was likened to mourning by Freud in his 1917 paper Mourning and Melancholia. He indicated the loss of a valued relationship resulted in subjective loss which resulted in severe melancholic symptoms more profound than mourning.

Psychoanalysis was being used to treat patients as there were no medication treatments in the 1920s. Freud had proposed the power of identification in groups as a determinant of behavior in his paper “Group Psychology and Analysis of Behavior”.

Davison K. Historical aspects of mood disorders. Psychiatry 2006; 5:115-118

Fast forward 100 years later the year 2020

The management of depression in the year 2020 is characterized by a wide range of treatment options. Currently, there is the DSM-5 classification of mental disorders which also helps distinguish major depressive disorder from bipolar disorder. We also have access to laboratory studies to help us treat mood disorders. These help us to detect medical illnesses such as thyroid problems known to be implicated in mood disorders. We can augment our assessments with psychological testing. This testing helps with IQ assessment as well as the detection of ADHD. We also recognize personality disorders and their role in patient outcomes. Another important feature has been the recognition of comorbid conditions in psychiatry and their implications in the treatment of depressive disorders. We have a wealth of important information available online which even patients have access to leading them to be empowered.

The role of neuroimaging in the diagnosis and treatment of depression is controversial at this time. The positron emission tomography scans and functional MRI have provided insights into the functioning of the brains of those with mood disorders but cannot be used for diagnosis. We do have rating scales such as the Patient Health Questionnaire-9 which help with the diagnosis and assessment of the severity of depressive symptoms. There are tools to conduct a suicide risk assessment such as the Columbia Suicide Scale and The Suicide Assessment Five-Step Evaluation and Triage (SAFE-T).

The role of monoamines (norepinephrine, dopamine, and serotonin) was studied in the pathogenesis of mood disorders, and more recently the glutamate system is under study particularly the NMDA receptor. Science has come a long way from the days of melancholia.

There are laws in place to both protect patient rights as well as to hospitalize and treat involuntarily if there is a serious risk of harm to self or others. A judge can order a patient to be retained in the hospital and treated involuntarily after a hearing. The patients now get due process.

To treat depressive disorders, we have data from multiple studies conducted using certified protocols with adequate protection of human subjects. There are several options of treatments available.

Evidence based psychotherapy has grown as a treatment option with multiple forms of this treatment to include Interpersonal Psychotherapy (IPT) and Psychoanalytic Psychotherapy an offshoot of psychoanalysis. Cognitive Behavioral Therapy (CBT) developed by Aaron Beck has become extremely popular in treating depression. There are therapies to treat specific disorders such as Exposure and Response Therapy to treat obsessive-compulsive disorder and Dialectical Behavioral Therapy (DBT) to treat borderline personality disorder. Other therapies such as Acceptance Commitment Therapy (ACT) are being used to help health care workers on the frontlines during the Covid-19 crises.

Medications to treat depression: There is an availability of a wide range of agents to choose from which are delivered in various formulations from tablets to liquids, intranasal spray, and intravenous infusions. The various categories include the tricyclic antidepressants (TCA), monoamine oxidase inhibitors (MAOI), SSRIs, SNRI, atypical antidepressants. The newer anti-depressants are safer in overdose compared with the older agents such as the tricyclics. We have augmentation strategies using medications like antipsychotic agents, lithium, thyroid hormone, and buspirone.

We are at this time studying the efficacy of psychedelic drugs such as LSD, psilocybin, MDMA, and ayahuasca which would be unthought of earlier. The use of intravenous ketamine and intranasal esketamine has gained significant traction.

Neurostimulation: There are multiple modalities available under this category of treatment. The most commonly used and the oldest is electroconvulsive therapy (ECT) an extremely efficacious treatment. Transcranial magnetic stimulation (TMS) involves using a magnetic field and does not need general anesthesia like ECT. Memory problems are also not an issue with this modality. Deep brain stimulation (DBS) and vagal nerve stimulation (VNS) are other modalities available for refractory depression.

Kennedy SH. Canadian network for mood and anxiety treatments (CANMAT). Clinical guidelines for the management of adults with major depressive disorder. Canadian Journal of Psychiatry 2016;6: 540-560

Clinical Commentary

Currently, the practice of psychiatry offers a lot of hope for patients suffering from severe depression. We have a slew of medications in our armamentarium which can be used from monotherapy to combination therapy. Also, medication treatments can be combined with various forms of psychotherapy. A good history and collateral information remain the best way to arrive at an accurate diagnosis. This helps us detect personality disorders that primarily benefit from psychotherapy.The treatment of depression has come a long way from the lack of any medications to a full range of medications, neurostimulation, and psychotherapies.

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Bipolar Disorder

The treatment of bipolar disorder a century ago and in the present 2020

The period of 1920

The Greeks and Romans were responsible for the term “mania” and “melancholia”. In the current times, they are referred to as "mania" and "depression". Emil Kraepelin in the early 20th century had coined the term manic depressive psychosis and differentiated this illness from schizophrenia in his works “Manic Depressive Insanity and Paranoia” in 1921. Kraepelin’s work remains the basis for classification used in modern times. This theory steers away from Freud’s thought that suppression of desires and society played a role in the causation of mental illness. There were no evidenced-based treatments at that time. The seriously ill were in asylums.

Mapother E. Discussion of manic-depressive psychosis. British Medical Journal 1926;2(3436):872-879

Fast forward 100 years later the year 2020

Today there are multiple well-established treatments for bipolar disorder. There is also recognition of bipolar II disorder characterized by the presence of hypomania, lack of functional impairment, and lack of psychosis. This subtype has mostly depressive episodes. We still miss bipolar I as well as II disorder and diagnose them erroneously as major depression or anxiety disorder based on the presenting symptoms. Currently, we are aware of the psychiatric comorbidities such as substance abuse and anxiety disorders which impact the outcome.

There is emerging evidence that links bipolar spectrum disorders with various system dysfunctions including the endocrine, immune, and autonomic systems.  This results in cardiometabolic issues shortening lifespan by a decade. Cardiovascular disease being the commonest cause of death and not suicide in this illness.

There is a better but not complete understanding of genetics. There are reports of overlap between bipolar illness, schizophrenia, major depression, attention deficit disorder, and an autism spectrum disorder. A recent genome-wide association study indicated that bipolar disorder may be more genetically related to schizophrenia rather than to major depression. NO specific gene is identified as yet but candidate genes appear to be shared risk factors between schizophrenia, bipolar illness, and major depression. The evidence points to a complex polygenetic pattern of inheritance involving a large number of genes with variable effects modified by epistasis, epigenetic modifications, and interactions with the environment.

We now have structural and functional neuroimaging studies suggesting brain abnormalities. There is noted to be an increase in the size of the lateral ventricles related to the number of manic episodes suggesting a reduction of brain tissue. The dysfunction of multiple neural networks has also been noted. This, in turn, is linked to dysregulation of the monoamine and glutamatergic systems. Dysfunction of limbic hypothalamic pituitary adrenal axis is well known in multiple psychiatric disorders including bipolar illness. There is a better understanding of inflammatory cytokines in bipolar illness and other psychiatric disorders.

There have been several treatments developed for bipolar disorder. Initially, there were more therapies targeted at mania but now therapies specifically are being developed for bipolar depression. There is also specific guidance when using antidepressants in treating bipolar illness. We also now are familiar with antidepressant-induced mania.

Several agents are used to treat bipolar illness including atypical antipsychotics with some also having approval for bipolar depression (quetiapine, lurasidone, and cariprazine and the olanzapine and fluoxetine combination). The mood stabilizers such as lithium, divalproex, carbamazepine, and lamotrigine are the pillars of treatment though the atypical antipsychotic agents are now gaining in popularity. We can assess the efficacy and safety of the mood stabilizers by therapeutic monitoring of blood levels.

Strakowski SM. CANMAT and ISBD 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders 2018; 20:393-394  

Clinical Commentary

The diagnosis and management of bipolar illness has changed substantially in the last 100 years. Still, we need to take a good longitudinal history and get collateral information. Most patients present with depression as the symptom needing treatment and we as clinicians need to extract clues about past manic/hypomanic episodes to clinch the diagnosis. We do have the mood disorder questionnaire, which is a helpful tool but does not replace history taking. This is still a remarkable issue as often these patients are still being treated for major depression.  We also should follow the guidelines for the use of antidepressants in this illness.

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Anxiety Disorders

The treatment of anxiety disorders a century ago and, in the present, (2020)

The treatment of anxiety in the period of 1920

In this period anxiety was noted to be an important component of many new diagnostic categories. These categories included neurasthenia to neurosis. Neurasthenia was first described by George Beard and this term has survived until current times and was included in the ICD-10.

Around the same time, Sigmund Freud had come up with the term anxiety neurosis. He identified two forms of anxiety. One form resulted from repressed libido and sexual tension which could be released by sexual intercourse. This resulted in conditions such as hypochondriasis, anxiety neurosis, and neurasthenia. The other form of anxiety was believed to originate from repressed thoughts or wishes.This particular form was responsible for phobias, obsessional neurosis, hysteria, and psychoneuroses. Freud subsequently changed his mind saying that it was anxiety that leads to repression and not as he had previously proposed. In this time frame, there was a focus on the autonomic symptoms associated with anxiety. Freud utilized psychoanalysis to treat anxiety disorders.

In 1917 Watson and Morgan theorized that Pavlov’s conditioning paradigm accounted for much emotional behavior in humans. This led to the foundations for behavior therapy for anxiety. Otto Rank who broke ranks with Freud and started existential therapy.

Fear is an alerting signal in response to a known external threat. Anxiety was thought to be in response to a threat that is unknown. During this time Kraepelin considered anxiety as a symptom associated with other diagnoses. Kraepelin wrote much less about anxiety being a separate diagnosis.

A century ago, there were no medications to treat anxiety disorders. Sigmund Freud was known for psychoanalysis or the “talking cure”. Behaviorism also played an important role during this time.

Marc-Antoine C. History of anxiety. Dialogues in Clinical Neuroscience 2015;17: 319-325

Fast forward 100 years later the year 2020

Anxiety and related disorders are the most common psychiatric illnesses as we know today  with the lifetime prevalence being as high as 30%. Today we recognize they are underdiagnosed and are comorbid with many psychiatric conditions such as major depression, substance use disorder (SUD), and bipolar disorder. They are comorbid with many medical conditions such as irritable bowel syndrome, cardiac problems, and respiratory problems such as asthma. There is also recognition that patients having anxiety are a tough to treat group and that there may be underlying personality disorders such as borderline personality disorder. Anxiety is recognized to be a symptom as well as a disease state. We also recognize that anxiety disorders are associated with a higher risk of suicide attempts. This risk is compounded by the prevalence of comorbid mood disorder.

The anxiety disorder category includes panic disorder, specific phobias, social anxiety disorder (SAD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD). We now have defined criteria to make a systematic diagnosis with reliability.

There is genetic evidence although greater for some disorders compared to others. Neuroanatomic sites have been outlined such as the locus ceruleus and the raphe nuclei which project to the limbic system and cerebral cortex. The role of the amygdala is being studied in PTSD. These insights are obtained through modern technology which included structural and functional imaging studies. Research has implicated three major neurotransmitters which include norepinephrine, serotonin, and gamma-aminobutyric acid (GABA). 

At present we have a multitude of psychotherapeutic treatments as well as somatic treatments. Based on clinical trials we have medications such as selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRI’s), azapirones, and benzodiazepines to help treat these disorders.

There is data to support the use of specialized psychotherapies in combination with pharmacological management. These include Cognitive behavioral therapy (CBT) for anxiety disorders, Exposure and response therapy for OCD), and eye movement desensitization and reprocessing (EMDR) for PTSD. There is also recognition of the role of mindfulness, meditation, and yoga.

Katzman MA. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress, and obsessive-compulsive disorders. BMC Psychiatry 2014; 14:1-83

Clinical Commentary

The management of anxiety disorders has been revolutionized in modern times. This includes the use of medicines such as benzodiazepines which can terminate acute anxiety, while long-term treatment with a medication and psychotherapy combination can be instituted. Recognition of comorbid anxiety in other psychiatric disorders provides clues to a tougher to treat patients. The utilization of technology such as smartphone apps is just taking off.

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Alcoholism

The treatment of alcoholism a century ago and in the present 2020

The treatment of alcoholism in the 1920s

During the early 20th century, degenerationism was thought to be associated with causing alcoholism. This theory stated that biological, environmental, and moral factors could cause multiple problems in a person's life and those flaws could be passed down to the next generation.  Alcoholism was considered part of this idea because it affected the medical and social aspects of a person’s life. In the United States, there was the Anti-Saloon League and subsequently the temperance movement that had a focus on the issues related to alcohol consumption. The temperance movement was an organized effort to reduce the consumption of alcoholic beverages. Prohibition was implemented between 1919 and 1933 which initially reduced alcohol intake. This increased illegal alcohol intake and subsequently prohibition was abolished for reasons other than it failed to reduced alcohol intake. The Great Depression came and it was argued that alcohol production would create employment generate revenues including taxes which may help lower income taxes.

In Germany, the heritable nature of alcoholism was recognized and with concerns of mental illness increasing, the medical doctors recommended sterilization of alcoholics which was enforced by the Nazi regime.

Mann K, Herman D, Heinz A. One hundred years of Alcoholism: the twentieth century. Alcohol & Alcoholism. 2000;35: 10-15

Fast forward 100 years later the year 2020

Alcohol dependence afflicts about 10% of the world’s population. The current management of alcohol dependence includes active screening with questionnaires such as the CAGE followed by a focus on outpatient management before the trial of the inpatient rehabilitation program. The modern-day concept of a disease state for alcoholism has been developed. We now have the 12 steps Alcoholics Anonymous (AA) program. We also better understand the comorbidities related to alcoholism such as anxiety disorders, bipolar illness, major depression, and post-traumatic stress disorder to name a few. The ultimate goal is abstinence but the concept of reduced drinking has also been acknowledged.

We also understand that multiple neurotransmitters such as dopamine, serotonin, and gamma-aminobutyric acid (GABA) may be directly or indirectly be affected by alcohol. There is also a realization that risk factors such as genetics, environmental factors, and cultural attitudes play a role in the development of alcohol dependence.

Management of alcohol withdrawal

There are established protocols now to manage alcohol withdrawal such as the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) in addition to vital signs parameters. Agents such as benzodiazepines and gabapentin are used to treat alcohol withdrawal.

Support Groups available:

AA is the 12-step program that in my opinion, all individuals with alcohol problems should attend. There are other support groups such as adult children of alcoholics (ACOA) which is also a 12-step program for those growing up in dysfunctional alcoholic families. Other such groups include Al-Anon, and Alateen (teenagers) which help those dealing with someone in their life who has alcohol issues and is impacting them. These have been a tremendous help to patients with alcohol dependence and their near and dear ones.

Medication treatments

There are now three FDA approved treatments namely disulfiram, naltrexone, and acamprosate. There is no ideal drug but it is well known that the combination of medication therapy in addition to counseling and AA meetings does help remarkably. Also, family support is key.

Disulfiram: Blocks aldehyde dehydrogenase leading to increased acetaldehyde levels when alcohol is consumed leading to symptoms such as dizziness, flushing, nausea, vomiting, convulsions, and respiratory depression and hence serves as a strong deterrent.

Naltrexone: This is a competitive opioid receptor antagonist. This medication combats the endogenous opioids released when an individual drinks alcohol resulting in acute rewarding properties. This agent reduces cravings for alcohol and if the individual does drink there is no toxic reaction. It is an effective treatment option however; the patient should be opioid-free for at least 7-10 days before initiating this therapy. The liver function should be in the normal range and needs to be monitored. There is also a long-acting injectable (monthly injection) form that helps with compliance issues.

Acamprosate: This agent is hypothesized to restore GABA and glutamate imbalances caused by alcohol dependence. Its mechanism of action is via the N-methyl-D-aspartic acid (NMDA) receptor. This agent may be a safer option than disulfiram or naltrexone in patients with hepatic impairment. There are inconsistencies between US and European studies regarding its results.

Combined therapies with the above agents are not significantly beneficial compared to monotherapy.

Currently it is well established that medication treatment should be combined with a motivational interview, cognitive behavioral therapy, management of the underlying psychiatric illness, and self-help groups such as AA.

Caputo F et al. Pharmacological management of alcohol dependence and beyond: From monotherapy to pharmacogenetics and beyond. European Neuropsychopharmacology 2014;24: 181-191

Clinical Commentary

The approach to alcoholism has changed radically in the last 100 years with the introduction of the disease model and compassionate treatment. It is now known that a combination of therapy and one of the FDA approved medication treatments work best. We also now have a LAI for naltrexone. Screening is the key followed by an assessment for underlying psychiatric illness.

Psychiatry in the 21st Century

  1. The diagnostic criteria for psychiatric disorders have been operationalized. Also, along with a significant reduction in stigma, there has been an improvement in patient rights. There is a recognition that psychological stability is the key to manage the overall patient including medical issues. Psychiatry is integrated into mainstream medicine.
  2. A significantly better understanding of genetics.
  3. Neuroimaging studies (functional and anatomical) providing clues with replicated findings but are still not diagnostic. Receptor occupancy studies are predictive of the mechanism of action as well as side-effects. There is an exploration of neuroscience leading to a better understanding of how the brain works.
  4. Availability of neuropsychological testing and laboratory studies to check organic function and measure therapeutic levels of medications.
  5. A sophisticated understanding of neurochemistry resulting in a wide range of newer and safer medications to treat the various psychiatric disorders. This has led to the field of drug development and clinical trials.This includes medications such as ketamine that can rapidly diminish suicidal ideation.
  6.  Understanding of the role of psychiatric and medical comorbidities.
  7. Development of psychotherapies which are operationalized.
  8. Long term follow-up and outcome data are now available.
  9. Availability of drugs for side-effects (TD) for which there never was an effective treatment before (drugs used to treat tardive dyskinesias)
  10. The use of rating scales in clinical practice to aid in diagnosis and follow treatment outcomes.
  11.  The field of interventional psychiatry (ECT, TMS, ketamine use, deep brain stimulation, and vagal nerve stimulation)
  12. A more sophisticated lethality assessment.
  13. We have guidelines now for the practice of psychiatry:

CANMAT guidelines

Texas Medication Algorithm Project (TMAP)

APA guidelines

Cochrane reviews

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Psychiatry has come a long way but a thorough longitudinal history and collateral information remain the cornerstone for an accurate diagnosis.


Sanjay Gupta, MD
Clinical Professor of Psychiatry, SUNY Buffalo

GME Research Review is a monthly newsletter edited by Sanjay Gupta, MD, Clinical Professor of Psychiatry, SUNY Buffalo. Dr. Gupta selects, summarizes, and provides a clinical commentary on the latest published research in psychiatry. 

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