Psychiatric Clinics of North America RSS feed: Current Issue. Psychiatric Clinics of North America updates you on the latest trends in patient management; keeps you up to date on the newest advances; and provides a sound basis for choosing treatment options. Each issue focuses on a single topic in psychiatry and is presented under the direction of an experienced guest editor. http://www.psych.theclinics.com/?rss=yesElsevier Inc.en © 2012 Published by Elsevier Inc. All rights reserved. Psychiatric Clinics of North America0193-953X351March 2012 © 2012 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.psych.theclinics.com/article/PIIS0193953X12000093/abstract?rss=yesContributors10.1016/S0193-953X(12)00009-3Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0iiivhttp://www.psych.theclinics.com/article/PIIS0193953X1200010X/abstract?rss=yesContents10.1016/S0193-953X(12)00010-XPsychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0viixihttp://www.psych.theclinics.com/article/PIIS0193953X12000111/abstract?rss=yesForthcoming Issues10.1016/S0193-953X(12)00011-1Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0xiixiihttp://www.psych.theclinics.com/article/PIIS0193953X12000032/abstract?rss=yes Thomas Kuhn, the noted philosopher of science, tells us that there is a predictable movement of scientific development. During periods of normal science, our understanding grows, and models of understanding become more precise. However, with increasing rigor, it becomes easier to appreciate the limits of any particular explanatory model. The eventual result is what he coined a “paradigm shift.” I am hopeful that there is a psychiatric paradigm shift in the making, which seems to be emerging around our treatment of depression.Integrative Approaches to Depression and Its TreatmentDavid L. Mintz10.1016/j.psc.2012.01.002Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0xiiixvihttp://www.psych.theclinics.com/article/PIIS0193953X11001134/abstract?rss=yesMajor depression is a commonly occurring, seriously impairing, and often recurrent mental disorder. The World Health Organization (WHO) ranks major depressive disorder (MDD) as the fourth leading cause of disability worldwide and projects that by 2020 it will be the second leading cause owing to currently unexplained increasing prevalence in recent cohorts. Although data on the prevalence and costs of MDD do not exist for most countries, psychiatric epidemiologic surveys of the general population, students, and primary care patients have been carried out in many developed countries as well as in an increasing number of developing countries. The results of these surveys are reviewed in this chapter. The paper begins with an overview of information on the descriptive epidemiology of major depression (prevalence, age of onset, course, comorbidity) and then focuses primarily on data documenting the individual and societal costs of depression.The Costs of DepressionRonald C. Kessler10.1016/j.psc.2011.11.005Psychiatric Clinics of North America 35, 1 (2012)2011-12-19Psychiatric Clinics of North America2011-12-19351S0193-953X(11)X0006-0114http://www.psych.theclinics.com/article/PIIS0193953X11001146/abstract?rss=yesConsider 2 cases from the same urban outpatient clinic in a large North American city. Mrs Liu is a married woman in her early 40s, a recent immigrant who arrived 2 years ago from Mainland China. Presenting complaints are “tiredness,” “bad sleep,” “difficulty paying attention,” and “headache.” She acknowledges low mood on direct questioning, which she sees as understandable given the impact of her other symptoms. Concentration problems are attributed to the effects of fatigue and insomnia, and she denies other psychological symptoms. Indeed, she openly wonders on several occasions, “Why does everyone here want to know about thoughts and feelings and so on?” She has few friends, has difficulties improving her English, and spends most days at home while her husband works, but does not see these issues as relevant to her current symptoms. Rather, they are part of what one expects from the migration experience, although she acknowledges that she prefers to discuss life difficulties with her one close friend rather than with health professionals. She is not willing to consider psychosocial interventions, but accepts treatment with a selective serotonin reuptake inhibitor when the purpose of the medication is clearly linked to relief of fatigue. Ms Chan is a single woman in her mid 30s, also a recent immigrant who arrived 5 years ago from Mainland China. Presenting complaints are “exhaustion,” “difficulty getting to sleep,” “no appetite,” and “depressed mood.” She agrees that psychosocial explanations are plausible, related to trouble finding permanent employment or a romantic partner, and admits to shame about “being weak.” “I am very embarrassed that I have this problem and I make sure my family back home doesn't know anything about it.” Pessimistic or even hopeless thoughts about the future are also acknowledged on direct questioning, but she does not really see these thoughts as symptoms; other psychological symptoms are denied. She is willing to consider antidepressant medication so long as it is not a permanent solution, but ends up dropping out of psychotherapy after 2 sessions. After a few months, she agrees to take part in weekly group therapy sessions emphasizing a skills approach for new immigrants, and completes the program with no sessions missed.Depression in Cultural Context: “Chinese Somatization,” RevisitedAndrew G. Ryder, Yulia E. Chentsova-Dutton10.1016/j.psc.2011.11.006Psychiatric Clinics of North America 35, 1 (2012)2011-12-19Psychiatric Clinics of North America2011-12-19351S0193-953X(11)X0006-01536http://www.psych.theclinics.com/article/PIIS0193953X11001158/abstract?rss=yesAlthough depression has been recognized by physicians, philosophers, and poets since ancient times, full recovery from depression was ill-defined and largely ignored in clinical practice until quite recently. Treatment was considered adequate or successful if a patient's mood and function seemed to be significantly better after treatment than before. The only measures of improvement were the patient's reports of function and symptom reduction. Persistent or chronic symptoms were largely regarded as characterological and were labeled depressive personality.Recovery from DepressionNada L. Stotland10.1016/j.psc.2011.11.007Psychiatric Clinics of North America 35, 1 (2012)2011-12-19Psychiatric Clinics of North America2011-12-19351S0193-953X(11)X0006-03749http://www.psych.theclinics.com/article/PIIS0193953X11001195/abstract?rss=yesMajor depression is a common disorder, accounting for more disability than any other disorder worldwide. The rates of major depression in the United States rose markedly in the decade from 1991 to 2001, from 3.33% to 7.06%. This increase is of considerable consequence, because depression is associated with significant morbidity, disability, increased medical comorbidities, and mortality. It is the most significant risk factor for suicide, a leading cause of death worldwide, especially in adolescents, young adults, and the elderly.Etiology of Depression: Genetic and Environmental FactorsRadu V. Saveanu, Charles B. Nemeroff10.1016/j.psc.2011.12.001Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-05171http://www.psych.theclinics.com/article/PIIS0193953X1100116X/abstract?rss=yes“Depression” is not simply depression. There are many varieties, with manic and anxiety symptoms being prominent aspects. To understand depression, we need to understand much beyond depression.The Varieties of Depressive Experience: Diagnosing Mood DisordersS. Nassir Ghaemi, Paul A. Vöhringer, Derick E. Vergne10.1016/j.psc.2011.11.008Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-07386http://www.psych.theclinics.com/article/PIIS0193953X11001110/abstract?rss=yesSelection of treatment according to evidence-based medicine relies primarily on randomized controlled trials and meta-analyses. However, this evidence applies to the “average” patient and ignores the fact that customary clinical taxonomy does not include patterns of symptoms, severity of illness, effects of comorbid conditions, timing of phenomena, rate of progression of illness, responses to previous treatments, and other clinical distinctions that demarcate major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar because they share the same diagnosis.Treatment Selection in Depression: The Role of Clinical JudgmentElena Tomba, Giovanni A. Fava10.1016/j.psc.2011.11.003Psychiatric Clinics of North America 35, 1 (2012)2012-01-16Psychiatric Clinics of North America2012-01-16351S0193-953X(11)X0006-08798http://www.psych.theclinics.com/article/PIIS0193953X11001067/abstract?rss=yesCognitive–behavioral therapy (CBT) for depression is one of the best researched treatments in all of medicine. As developed by Aaron T. Beck in the 1970s, CBT for depression employs the highly potent strategies of behavioral activation and the relapse-preventing interventions of belief change and cognitive restructuring. As this article discusses, CBT is also substantially more durable than medication in patients who respond to treatment. Because not all patients with depression respond to medication, and many continue to have residual symptoms that interfere with their quality of life and incur a risk for relapse, CBT can play a major role in the treatment of this significant, often deadly public health problem.Cognitive Behavioral Therapy for DepressionDonna M. Sudak10.1016/j.psc.2011.10.001Psychiatric Clinics of North America 35, 1 (2012)2011-12-06Psychiatric Clinics of North America2011-12-06351S0193-953X(11)X0006-099110http://www.psych.theclinics.com/article/PIIS0193953X12000020/abstract?rss=yesOver the last 2 decades, there has been a remarkable increase in research into psychodynamic treatments (PT) for depression. This article reviews the key theoretical assumptions of PT for depression and summarizes findings concerning the efficacy and effectiveness of these interventions alone and in combination with pharmacotherapy in adults, children, and adolescents. Issues of suitability and acceptability are also discussed as well insights into the mutative factors in these treatments. We close this article with a summary and implications for future research and treatment guidelines.Psychodynamic Treatment of DepressionPatrick Luyten, Sidney J. Blatt10.1016/j.psc.2012.01.001Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0111129http://www.psych.theclinics.com/article/PIIS0193953X11001109/abstract?rss=yesThis article reviews recent studies and controversies about the effectiveness of antidepressant medications for depression. These medications are used for treatment of a wide variety of nondepressive conditions. Most notably, selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are often prescribed for most anxiety disorders, and they are clearly effective in this sphere, with robust differences between active drugs and placebos in controlled clinical trials. As one studies the contentious literature on antidepressants for depression, it is important to not lose sight of the fact that the very term “antidepressant” has become anachronistic. These drugs are actually broad-spectrum emotional and physical pain-relieving agents with efficacy in depression, anxiety, insomnia, as well several nonpsychiatric pain syndromes such as migraines, irritable bowel syndrome, neuropathies, and fibromyalgia.Evidence-Based Somatic Treatment of Depression in AdultsDaniel Carlat10.1016/j.psc.2011.11.002Psychiatric Clinics of North America 35, 1 (2012)2011-12-12Psychiatric Clinics of North America2011-12-12351S0193-953X(11)X0006-0131142http://www.psych.theclinics.com/article/PIIS0193953X11001171/abstract?rss=yesOver the past 2 decades psychiatry has benefited from an increasingly evidence-based perspective and a proliferation of safer and more tolerable antidepressant treatments. Despite these advances, however, there is no evidence that treatment outcomes are better than they were a quarter of a century ago. New psychiatric medications come on the market every year, often with great enthusiasm, only to be tempered by the realities of clinical practice. More recently, it seems that novel antidepressants have not even been able to generate much fanfare. This phenomenon is not particularly surprising considering that the widely publicized STAR*D trial reported relatively underwhelming performances of various psychopharmacologic agents when applied in real-world settings. One possible explanation for the failed promise of psychopharmacology rests in the fact that the field has been so enthusiastic about biological treatments that psychosocial aspects of psychopharmacology have been almost entirely neglected in recent years.How (Not What) to Prescribe: Nonpharmacologic Aspects of PsychopharmacologyDavid L. Mintz, David F. Flynn10.1016/j.psc.2011.11.009Psychiatric Clinics of North America 35, 1 (2012)2011-12-16Psychiatric Clinics of North America2011-12-16351S0193-953X(11)X0006-0143163http://www.psych.theclinics.com/article/PIIS0193953X11001079/abstract?rss=yesMultiple medications and some forms of psychotherapy have demonstrated efficacy in the treatment of depression. However, despite these interventions, many patients continue to respond only partially to available treatments and nonadherence to medication is common, adding to the tendency of depression to recur. Many clinicians believe that a combination of medication and psychotherapy provides the greatest potential for long-term relief of depression, and a number of studies have focused on the relative value of combined compared to single treatments.Combined Treatment of DepressionFredric N. Busch, Larry S. Sandberg10.1016/j.psc.2011.10.002Psychiatric Clinics of North America 35, 1 (2012)2011-12-05Psychiatric Clinics of North America2011-12-05351S0193-953X(11)X0006-0165179http://www.psych.theclinics.com/article/PIIS0193953X11001201/abstract?rss=yesDepression is among the most common of all illnesses, affecting over 16% of all individuals in the United States at some time in their lives. Because of its recurrent nature, treatment resistance, lack of treatment, or a combination thereof, 85% of those with depression will suffer recurrence within 15 years. Youth experience depression at significant rates as well. Recently published results from the National Comorbidity Study–Adolescent Supplement reveal a lifetime prevalence of major depressive disorder or dysthymia of 11.2% of 13- to 18-year-olds, with a 3.3% lifetime prevalence of a severe depressive disorder in that same age group. The 2008 National Survey on Drug Use and Health, sponsored yearly by the Substance Abuse and Mental Health Services Administration, shows the prevalence of depression among 12- to 17-year-olds to be 8.3%, with girls showing 3 times the prevalence as boys. One-year prevalence rates for major depression are approximately 2% in childhood and 4% to 7% in adolescence. Depression in adolescence is associated with increased risks of substance abuse and dependence and academic, occupational, interpersonal, and other social difficulties. Suicide risk is significantly increased in youth with depressive disorders and is the third leading cause of death in adolescents. Data published by the Centers for Disease Control and Prevention report that over a 1-year period of time studied, 13.8% of American adolescents considered killing themselves, 10.9% had made plans, and 6.3% actually reported attempting suicide.Child and Adolescent Depression: Psychotherapeutic, Ethical, and Related Nonpharmacologic Considerations for General Psychiatrists and Others Who PrescribeMary Lynn Dell10.1016/j.psc.2011.12.002Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0181201http://www.psych.theclinics.com/article/PIIS0193953X12000044/abstract?rss=yesAmong older adults, depressive symptoms and syndromes can present differently than in younger populations. Their demographics, phenomenology, assessment, comorbidity pattern, treatment approach, and typical locus of treatment are discussed here with emphasis on the special characteristics of depression as it presents in later life. Discussion of bipolar disorder, bipolar depression, and more extensive reviews of major depressive disorder can be found in several comprehensive recent texts.Depression in Later Life: An Overview with Treatment RecommendationsJames M. Ellison, Helen H. Kyomen, David G. Harper10.1016/j.psc.2012.01.003Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0203229http://www.psych.theclinics.com/article/PIIS0193953X11001092/abstract?rss=yes“Depression” in medically ill patients is first and foremost a phenotype. Many underlying etiologies may take a final common pathway of producing such a phenotype, but have divergent implications for prognosis and management. Thus appropriate management requires first establishing the most likely diagnosis that has caused depression to be considered. This article reviews common etiologies for a “depressed” appearance in medically ill patients and proposes management strategies in each sphere of the bio-psycho-social-spiritual model.Depression in Medically Ill PatientsSandra Rackley, J. Michael Bostwick10.1016/j.psc.2011.11.001Psychiatric Clinics of North America 35, 1 (2012)2011-12-19Psychiatric Clinics of North America2011-12-19351S0193-953X(11)X0006-0231247http://www.psych.theclinics.com/article/PIIS0193953X11001122/abstract?rss=yesThe effectiveness of treatments for depression is suboptimal for a significant portion of individuals diagnosed with depressive illnesses. At least 20% do not respond satisfactorily and approximately 50% will experience a chronic or recurrent course of illness. Patients who have not responded adequately to evidence-based treatments after receiving adequate doses for an appropriate duration are said to have treatment-resistant depression (TRD). Many definitions of treatment resistance have been proposed. Eleven terms and six criteria have been used to describe resistance/refractoriness to treatment.Management of Treatment-Resistant DepressionGabor I. Keitner, Abigail K. Mansfield10.1016/j.psc.2011.11.004Psychiatric Clinics of North America 35, 1 (2012)2011-12-23Psychiatric Clinics of North America2011-12-23351S0193-953X(11)X0006-0249265http://www.psych.theclinics.com/article/PIIS0193953X12000123/abstract?rss=yesIndex10.1016/S0193-953X(12)00012-3Psychiatric Clinics of North America 35, 1 (2012)2012-03-01Psychiatric Clinics of North America2012-03-01351S0193-953X(11)X0006-0267277