Category: Psychiatry

Johns Hopkins clinical pharmacologist Roland Griffiths talks about a major new study hinting at psychedelic drugs as therapeutic powerhouses

On By A.P.In psychedelic, PsychiatryLeave a comment

By Richard Schiffman

In one of the largest and most rigorous clinical investigations of psychedelic drugs to date, researchers at Johns Hopkins University and New York University have found that a single dose of psilocybin—the psychoactive compound in “magic” mushrooms—substantially diminished depression and anxiety in patients with advanced cancer.

Psychedelics were the subject of a flurry of serious medical research in the 1960s, when many scientists believed some of the mind-bending compounds held tremendous therapeutic promise for treating a number of conditions including severe mental health problems and alcohol addiction. But flamboyant Harvard psychology professor Timothy Leary—one of the top scientists involved—started aggressively promoting LSD as a consciousness expansion tool for the masses, and the youth counterculture movement answered the call in a big way. Leary lost his job and eventually became an international fugitive. Virtually all legal research on psychedelics shuddered to a halt when federal drug policies hardened in the 1970s.

The decades-long research blackout ended in 1999 when Roland Griffiths of Johns Hopkins was among the first to initiate a new series of studies on psilocybin. Griffiths has been called the grandfather of the current psychedelics research renaissance, and a 21st-century pioneer in the field—but the soft-spoken investigator is no activist or shaman/showman in the mold of Leary. He’s a scientifically cautious clinical pharmacologist and author of more than 300 studies on mood-altering substances from coffee to ketamine.

Much of Griffiths’ fascination with psychedelics stems from his own mindfulness meditation practice, which he says sparked his interest in altered states of consciousness. When he started administering psilocybin to volunteers for his research, he was stunned that more than two-thirds of the participants rated their psychedelic journey one of the most important experiences of their lives.

Griffiths believes that psychedelics are not just tools for exploring the far reaches of the human mind. He says they show remarkable potential for treating conditions ranging from drug and alcohol dependence to depression and post-traumatic stress disorder.

They may also help relieve one of humanity’s cruelest agonies: the angst that stems from facing the inevitability of death. In research conducted collaboratively by Griffiths and Stephen Ross, clinical director of the NYU Langone Center of Excellence on Addiction, 80 patients with life-threatening cancer in Baltimore and New York City were given laboratory-synthesized psilocybin in a carefully monitored setting, and in conjunction with limited psychological counseling. More than three-quarters reported significant relief from depression and anxiety—improvements that remained during a follow-up survey conducted six months after taking the compound, according to the double-blind study published December 1 in The Journal of Psychopharmacology.

“It is simply unprecedented in psychiatry that a single dose of a medicine produces these kinds of dramatic and enduring results,” Ross says. He and Griffiths acknowledge that psychedelics may never be available on the drugstore shelf. But the scientists do envision a promising future for these substances in controlled clinical use. In a wide-ranging interview, Griffiths told Scientific American about the cancer study and his other work with psychedelics—a field that he says could eventually contribute to helping ensure our survival as a species.

[An edited transcript of the interview follows.]

What were your concerns going into the cancer study?
The volunteers came to us often highly stressed and demoralized by their illness and the often-grueling medical treatment. I felt very cautious at first, wondering if this might not re-wound people dealing with the painful questions of death and dying. How do we know that this kind of experience with this disorienting compound wouldn’t exacerbate that? It turns out that it doesn’t. It does just the opposite. The experience appears to be deeply meaningful spiritually and personally, and very healing in the context of people’s understanding of their illness and how they manage that going forward.

Could you describe your procedure?
We spent at least eight hours talking to people about their cancer, their anxiety, their concerns and so on to develop good rapport with them before the trial. During the sessions there was no specific psychological intervention—we were just inviting people to lie on the couch and explore their own inner experience.

What did your research subjects tell you about that experience?
There is something about the core of this experience that opens people up to the great mystery of what it is that we don’t know. It is not that everybody comes out of it and says, ‘Oh, now I believe in life after death.’ That needn’t be the case at all. But the psilocybin experience enables a sense of deeper meaning, and an understanding that in the largest frame everything is fine and that there is nothing to be fearful of. There is a buoyancy that comes of that which is quite remarkable. To see people who are so beaten down by this illness, and they start actually providing reassurance to the people who love them most, telling them ‘it is all okay and there is no need to worry’— when a dying person can provide that type of clarity for their caretakers, even we researchers are left with a sense of wonder.

Was this positive result universal?
We found that the response was dose-specific. The larger dose created a much larger response than the lower dose. We also found that the occurrence of mystical-type experiences is positively correlated with positive outcomes: Those who underwent them were more likely to have enduring, large-magnitude changes in depression and anxiety.

Did any of your volunteers experience difficulties?
There are potential risks associated with these compounds. We can protect against a lot of those risks, it seems, through the screening and preparation procedure in our medical setting. About 30 percent of our people reported some fear or discomfort arising sometime during the experience. If individuals are anxious, then we might say a few words, or hold their hand. It is really just grounding them in consensual reality, reminding them that they have taken psilocybin, that everything is going to be alright. Very often these short-lived experiences of psychological challenge can be cathartic and serve as doorways into personal meaning and transcendence—but not always.

Where do you go from here?
The Heffter Research Institute, which funded our study, has just opened a dialogue with the FDA (Food and Drug Administration) about initiating a phase 3 investigation. A phase 3 clinical trial is the gold standard for determining whether something is clinically efficacious and meets the standards that are necessary for it to be released as a pharmaceutical. Approval would be under very narrow and restrictive conditions initially. The drug might be controlled by a central pharmacy, which sends it to clinics that are authorized to administer psilocybin in this therapeutic context. So this is not writing a prescription and taking it home. The analogy would be more like an anesthetic being dispensed and managed by an anesthesiologist.

You are also currently conducting research on psilocybin and smoking.
We are using psilocybin in conjunction with cognitive behavioral therapy with cigarette smokers to see if these deeply meaningful experiences that can happen with psilocybin can be linked with the intention and commitment to quit smoking, among people who have failed repeatedly to do so. Earlier we ran an uncontrolled pilot study on that in 50 volunteers, in which we had 80 percent abstinence rates at six months. Now we are doing a controlled clinical trial in that population.

How do you account for your remarkable initial results?
People who have taken psilocybin appear to have more confidence in their ability to change their own behavior and to manage their addictions. Prior to this experience, quite often the individual feels that they have no freedom relative to their addiction, that they are hooked and they don’t have the capacity to change. But after an experience of this sort—which is like backing up and seeing the larger picture—they begin to ask themselves ‘Why would I think that I couldn’t stop cigarette smoking? Why would I think that this craving is so compelling that I have to give in to it?’ When the psilocybin is coupled with cognitive behavioral therapy, which is giving smokers tools and a framework to work on this, it appears to be very helpful.

You are also working with meditation practitioners. Are they having similar experiences?
We have done an unpublished study with beginning meditators. We found that psilocybin potentiates their engagement with their spiritual practice, and it appears to boost dispositional characteristics like gratitude, compassion, altruism, sensitivity to others and forgiveness. We were interested in whether the psilocybin used in conjunction with meditation could create sustained changes in people that were of social value. And that appears to be the case.

So it is actually changing personality?
Yes. That is really interesting because personality is considered to be a fixed characteristic; it is generally thought to be locked down in an individual by their early twenties. And yet here we are seeing significant increases in their “openness” and other pro-social dimensions of personality, which are also correlated with creativity, so this is truly surprising.

Do we know what is actually happening in the brain?
We are doing neuro-imaging studies. Dr. Robin Carhart-Harris’s group at Imperial College in London is also doing neuro-imaging studies. So it is an area of very active investigation. The effects are perhaps explained, at least initially, by changes in something [in the brain] called “the default mode network,” which is involved in self-referential processing [and in sustaining our sense of ego]. It turns out that this network is hyperactive in depression. Interestingly, in meditation it becomes quiescent, and also with psilocybin it becomes quiescent. This may correlate with the experience of clarity of coming into the present moment.

That is perhaps an explanation of the acute effects, but the enduring effects are much less clear, and I don’t think that we have a good handle on that at all. Undoubtedly it is going to be much more complex than just the default mode network, because of the vast interconnectedness of brain function.

What are the practical implications of this kind of neurological and therapeutic knowledge of psychedelics?
Ultimately it is not really about psychedelics. Science is going to take it beyond psychedelics when we start understanding the brain mechanisms underlying this and begin harnessing these for the benefit of humankind.

The core mystical experience is one of the interconnectedness of all people and things, the awareness that we are all in this together. It is precisely the lack of this sense of mutual caretaking that puts our species at risk right now, with climate change and the development of weaponry that can destroy life on the planet. So the answer is not that everybody needs to take psychedelics. It is to understand what mechanisms maximize these kinds of experiences, and to learn how to harness them so that we don’t end up annihilating ourselves.

https://www.scientificamerican.com/article/psilocybin-a-journey-beyond-the-fear-of-death/

Computer Algorithms Accurately Identify Suicidal Patients

On By A.P.In Psychiatry, suicideLeave a comment


by Jolynn Tumolo

By analyzing a patient’s spoken and written words, computer tools classified with up to 93% accuracy whether the person was suicidal, in a study published online in Suicide and Life-Threatening Behavior.

“While basic sciences provide the opportunity to understand biological markers related to suicide,” researchers wrote, “computer science provides opportunities to understand suicide thought markers.”

The study included 379 patients from emergency departments, inpatient centers, and outpatient centers at 3 sites. Researchers classified 130 of the patients as suicidal, 126 as mentally ill but not suicidal, and 123 as controls with neither mental illness nor suicidality.

Patients completed standardized behavioral rating scales and participated in semi-structured interviews. Five open-ended questions were used to stimulate conversation, including “Do you have hope?” “Are you angry?” and “Does it hurt emotionally?”

Using machine learning algorithms to analyze linguistic and acoustic characteristics in patients’ responses, computers were 93% accurate in classifying a person who was suicidal and 85% accurate in identifying whether a person was suicidal, had a mental illness but was not suicidal, or was neither.

“These computational approaches provide novel opportunities to apply technological innovations in suicide care and prevention, and it surely is needed,” said study lead author John Pestian, PhD, a professor in the divisions of biomedical informatics and psychiatry at Cincinnati Children’s Hospital Medical Center in Ohio.

“When you look around health care facilities, you see tremendous support from technology, but not so much for those who care for mental illness. Only now are our algorithms capable of supporting those caregivers. This methodology easily can be extended to schools, shelters, youth clubs, juvenile justice centers, and community centers, where earlier identification may help to reduce suicide attempts and deaths.”

References

Pestian JP, Sorter M, Connolly B, et al. A machine learning approach to identifying the thought markers of suicidal subjects: a prospective multicenter trial. Suicide and Life-Threatening Behavior. 2016 November 3;[Epub ahead of print].

Using a patient’s own words machine learning automatically identifies suicidal behavior [press release]. Cincinnati, OH: Cincinnati Children’s Hospital Medical Center; November 7, 2016.

Dark treatment for people with mania

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By James Phelps, MD

If light is an antidepressant (true) and antidepressants can make bipolar disorders worse (true), can darkness make bipolar disorders better? Might darkness be anti-manic?

This idea was explored over 2 decades ago, with a stunningly successful case report from the National Institute of Mental Health (NIMH) demonstrating that in at least 1 patient, darkness was indeed a mood stabilizer (1). But the protocol was arduous: 14 hours of enforced darkness every night.

It was so effective, they backed off to 10 hours, from 10 pm to 8 am, which kept the patient well with no medications for over a year. Yet, as clinicians know, patients still resist giving up their electric light, especially their TVs, tablets, and phones.

Hold that thought; and consider a completely separate line of research, which found that all wavelengths of light are not created equal. Blue light is by far the most powerful in setting circadian rhythm.

A new retinal photoreceptor, not a rod or cone, was discovered in 2001; it is sensitive primarily to blue light (2). These receptors connect not to the visual cortex but to the suprachiasmatic nucleus of the hypothalamus, wherein resides the primary biological clock. They are “circadian photoreceptors.”

Now put these 2 lines of research together. At night, when evolutionarily we should have 8 to 14 hours of darkness, one can create “virtual darkness” by blocking just the blue wavelengths of light. This can be done at the source (F.lux for Windows; NightShift for recent Apple products; and lowbluelights.com for no-blue bulbs and nightlights) or by simply donning a pair of amber-colored safety glasses.

The latter are available as fit-over-glasses, # S0360X; or a stylish version for young people with good eyes, # 3S1933X (purchase from Amazon—or, in a fun twist, from your local Airgas welding shop, ~$9). These safety glasses have been shown to preserve melatonin production at night even in a fully lit environment.3 About 50% of patients responded to wearing the amber lenses with reduced sleep latency and improved sleep quality (4).

But now the acid test: if darkness is a mood stabilizer, and if amber lenses produce physiologic darkness, then can the lenses treat acute mania?

This has just been shown quite conclusively(5) (to the extent that a single randomized trial is conclusive; but note this is a replication of another small inpatient study that used real darkness and found similar, though slightly less robust results (6).

In the new study from Norway, patients being admitted with bipolar mania were randomized to wear amber lenses or control clear lenses whenever they were not in real darkness during the 14-hour period from 6 pm to 8 am.

Thus, they replicated the intervention from the NIMH case report, using either real or “virtual darkness” with the amber lenses. The intervention began near admission and continued for 7 days, during which all participants received other treatments, including anti-manic medications, per usual.

Young Mania Rating Scale (YMRS) scores plummeted in the amber lenses group while those of the control group diminished only slightly: starting from a mean YMRS of 25, reductions were 14.1 vs 1.7, respectively.

Unfortunately, the sample size was smaller than originally intended because of growing public awareness of the effects of blue light and blue light–blocking glasses and consequently the patients knew what effect to expect. Thus, this may be the only such study we’ll ever see, and it took 10 years to replicate the first inpatient study6 of dark therapy.

So I hope that this new Norwegian study will not be dismissed as a pilot. The data are in. Time to move dark therapy into regular practice, as has already been suggested in the latest bipolar-specific psychotherapy, “CBT-IB: A Bipolar-Specific, All-Around Psychotherapy.”

But patients are often hesitant to increase their exposure to darkness: it means giving up things they value, especially television and other electronic entertainment. Blue light blockade can be much more acceptable.

http://www.psychiatrictimes.com/bipolar-disorder/new-zero-risk-treatment-mania/page/0/2?GUID=C523B8FD-3416-4DAC-8E3C-6E28DE36C515&rememberme=1&ts=12082016

Reduced activity of an important enzyme identified among suicidal patients

On By A.P.In Psychiatry, suicideLeave a comment

It is known that people who have attempted suicide have ongoing inflammation in their blood and spinal fluid. Now, a collaborative study from research teams in Sweden, the US and Australia published in Translational Psychiatry shows that suicidal patients have a reduced activity of an enzyme that regulates inflammation and its byproducts.

The study is the result of a longstanding partnership between the research teams of Professor Sophie Erhardt, Karolinska Institutet, Professor Lena Brundin at Van Andel Research Institute in Grand Rapids, USA, and Professor Gilles Guillemin at Macquarie University in Australia. The overall aim of the research is to find ways to identify suicidal patients.

Biological factors

“Currently, there are no biomarkers for psychiatric illness, namely biological factors that can be measured and provide information about the patient’s psychiatric health. If a simple blood test can identify individuals at risk of taking their lives, that would be a huge step forward”, said Sophie Erhardt, a Professor at the Department of Physiology and Pharmacology at the Karolinska Institutet, who led the work along with Lena Brundin.

The researchers analyzed certain metabolites, byproducts formed during infection and inflammation, in the blood and cerebrospinal fluid from patients who tried to take their own lives. Previously it has been shown that such patients have ongoing inflammation in the blood and cerebrospinal fluid. This new work has succeeded in showing that patients who have attempted suicide have reduced activity of an enzyme called ACMSD, which regulates inflammation and its byproducts.

“We believe that people who have reduced activity of the enzyme are especially vulnerable to developing depression and suicidal tendencies when they suffer from various infections or inflammation. We also believe that inflammation is likely to easily become chronic in people with impaired activity of ACMSD,” said Brundin

Important balance

The substance that the enzyme ACMSD produces, picolinic acid, is greatly reduced in both plasma and in the spinal fluid of suicidal patients. Another product, called quinolinic acid, is increased. Quinolinic acid is inflammatory and binds to and activates glutamate receptors in the brain. Normally, ACMSD produces picolinic acid at the expense of quinolinic acid, thus maintaining an important balance.

“We now want to find out if these changes are only seen in individuals with suicidal thoughts or if patients with severe depression also exhibit this. We also want to develop drugs that might activate the enzyme ACMSD and thus restore the balance between quinolinic and picolinic acid,” Erhardt said.

The study was funded with the support of the Swedish Research Council, Region Skåne and Central ALF funds. Additional support came from National Institute of Mental Health (NIMH), the American Foundation for Suicide Prevention, Van Andel Research Institute, Rocky Mountain MIRECC, the Merit Review CSR & D and the Joint Institute for Food Safety and Applied Nutrition (University of Maryland), and the Australian Research Council. Several of the researchers have indicated that they have business interests, which are recognized in the article.

Publication

An enzyme in the kynurenine pathway that governs vulnerability to suicidal behavior by regulating excitotoxicity and neuroinflammation
Lena Brundin, Carl M. Sellgren, Chai K. Lim, Jamie Grit, Erik Palsson, Mikael Landen, Martin Samuelsson, Christina Lundgren, Patrik Brundin, Dietmar Fuchs, Teodor T. Postolache, Lil Träskman-Bendz, Gilles J. Guillemin, Sophie Erhardt.
Translational Psychiatry, published online August 2, 2016, doi: 10.1038 / TP.2016.133.

http://ki.se/en/news/reduced-activity-of-an-important-enzyme-identified-among-suicidal-patients

Psychiatry’s Identity Crisis

On By A.P.In Medicine, Psychiatry, psychologyLeave a comment

psych

By Richard A Friedman, a professor of clinical psychiatry at Weill Cornell Medical College

American psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.

Even the new brain stimulatory treatments like repetitive transcranial magnetic stimulation don’t come close to the efficacy of electroconvulsive treatment, developed in the 1940s. (Deep brain stimulation is promising as a treatment for intractable depression, but it is an invasive treatment and little is known about its long-term safety or efficacy.)

At the same time, judging from research funding priorities, it seems that leaders in my field are turning their backs on psychotherapy and psychotherapy research. In 2015, 10 percent of the overall National Institute of Mental Health research funding has been allocated to clinical trials research, of which slightly more than half — a mere 5.4 percent of the whole research allotment — goes to psychotherapy clinical trials research.

As a psychiatrist and psychopharmacologist who loves neuroscience, I find this trend very disturbing. First, psychotherapy has been shown in scores of well-controlled clinical trials to be as effective as psychotropic medication for very common psychiatric illnesses like major depression and anxiety disorders; second, a majority of Americans clearly prefer psychotherapy to taking medication. For example, in a meta-analysis of 34 studies, Dr. R. Kathryn McHugh at McLean Hospital found that patients were three times more likely to want psychotherapy than psychotropic drugs.

Finally, many of our patients have histories of trauma, sexual abuse, the stress of poverty or deprivation. There is obviously no quick biological fix for these complex problems.

Still, there has been a steady decline in the number of Americans receiving psychotherapy along with a concomitant increase in the use of psychotropic medication in those who are treated in the outpatient setting. These trends are most likely driven by many factors, including cost and the limited availability that most Americans have to mental health practitioners. It is clearly cheaper and faster to give a pill than deliver psychotherapy.

The doubling down on basic neuroscience research seems to reflect the premise that if we can unravel the function of the brain, we will have a definitive understanding of the mind and the causes of major psychiatric disorders. Indeed, an editorial in May in one of the most respected journals in our field, JAMA Psychiatry, echoed this view: “The diseases that we treat are diseases of the brain,” the authors wrote.

Even if this premise were true — and many would consider it reductionist and simplistic — an undertaking as ambitious as unraveling the function of the brain would most likely take many years. Moreover, a complete understanding of neurobiology is unlikely to elucidate the complex interactions between genes and the environment that lie at the heart of many mental disorders. Anyone who thinks otherwise should remember the Decade of the Brain, which ended 15 years ago without yielding a significant clue about the underlying causes of psychiatric illnesses.

Sure, we now have astounding new techniques for studying the brain, like optogenetics, in which neurons can be controlled by light, allowing researchers to understand how neurons work alone and in networks. But no one thinks breakthrough biological treatments are just around the corner.

More fundamentally, the fact that all feelings, thoughts and behavior require brain activity to happen does not mean that the only or best way to change — or understand — them is with medicine. We know, for instance, that not all psychiatric disorders can be adequately treated with biological therapy. Personality disorders, like borderline and narcissistic personality disorders, which are common and can cause impairment and suffering comparable to that of severe depression, are generally poorly responsive to psychotropic drugs, but are very treatable with various types of psychotherapy.

There is often no substitute for the self-understanding that comes with therapy. Sure, as a psychiatrist, I can quell a patient’s anxiety, improve mood and clear psychosis with the right medication. But there is no pill — and probably never will be — for any number of painful and disruptive emotional problems we are heir to, like narcissistic rage and paralyzing ambivalence, to name just two.

This requires patients to re-experience the circumstances of their traumatic event, which is meant to desensitize them and teach them that their belief that they are in danger is no longer true.

But we know that many patients with PTSD do not respond to exposure, and many of them find the process emotionally upsetting or intolerable.

Dr. John C. Markowitz, a professor of clinical psychiatry at Columbia University, recently showed for the first time that PTSD is treatable with a psychotherapy that does not involve exposure. Dr. Markowitz and his colleagues randomly assigned a group of patients with PTSD to one of three treatments: prolonged exposure, relaxation therapy and interpersonal psychotherapy, which focuses on patients’ emotional responses to interpersonal relationships and helps them to solve problems and improve these relationships. His federally funded study, published in May’s American Journal of Psychiatry, reported that the response rate to interpersonal therapy (63 percent) was comparable to that of exposure therapy (47 percent).

PTSD is a serious public mental health problem, particularly given the rates of PTSD in our veterans returning from war. This study now gives clinicians a powerful new therapy for this difficult-to-treat disorder. Imagine how many more studies like Dr. Markowitz’s might be possible if the federal funding of psychotherapy research were not so stingy.

The brain is notoriously hard to study and won’t give up its secrets easily. In contrast, psychotherapy research can yield relatively quick and powerful results. Given the critically important value — and popularity — of therapy, psychotherapy research deserves a much larger share of research dollars than it currently receives.

Don’t get me wrong. I’m all for cutting-edge neuroscience research — and lots of it. But we are more than a brain in a jar. Just ask anyone who has benefited from psychotherapy.

The Healing Power of Caring and Hope in Psychotherapy

On By A.P.In psychiatrist, Psychiatry, psychologist, psychologyLeave a comment

By Allen Frances, MD

There are 3 consistent research findings that should make a world of difference to therapists and to the people they treat.

1. Psychotherapy works at least as well as drugs for most mild to moderate problems and, all things being equal, should be used first

2. A good relationship is much more important in promoting good outcome than the specific psychotherapy techniques that are used

3. There is a very high placebo response rate for all sorts of milder psychiatric and medical problems

This is partly a “time effect”—people come for help at particularly bad times in their lives and are likely to improve with time even if nothing is done. But placebo response also reflects the magical power of hope and expectation. And the effect is not just psychological—the body often actually responds to placebo just as it would respond to active medication.

These 3 findings add up to one crucial conclusion—the major focus of effective therapy should be to establish a powerfully healing relationship and to inspire hope. Specific techniques help when they enhance the primary focus on the relationship; they hurt when they distract from it.

The paradox is that therapists are increasingly schooled in specific techniques to the detriment of learning how to heal. The reason is clear—it is easy to manualize technique, hard to teach great healing.

I have, therefore, asked a great healer, Fanny Marell, a Swedish social worker and licensed psychotherapist, to share some of her secrets. Ms Marell writes:

Many therapists worry so much about assessing symptoms, performing techniques, and filling out forms that they miss the wonderful vibrancy of a strong therapeutic relationship.

Thinking I can help someone just by asking about concerns, troubles, and symptoms is like thinking that I can drive a car solely by looking in the rearview mirror. Dreams, hopes, and abilities are seen out of the front window of the car and help us together to navigate the road ahead. Where are we going? Which roads will you choose and why? It surely will not be the same roads I would take. We are different—we have to find your own best direction.

If we focus only on troubles and diagnosis, we lose the advantage of capitalizing on the person’s strengths and resources. If I am to help someone overcome symptoms, change behaviors, and climb out of difficult situations, I need to emphasize also all the positives he brings to the situation. Therapy without conversations about strengths and hopes is not real therapy.

And often most important: Does the patient have a sense of humor? Laugh together! Be human. No one wants a perfect therapist. It is neither credible nor human.

Symptom checklists and diagnoses play a role but they do not give me an understanding of how this person/patient understands his world and her troubles.

And don’t drown in manuals, missing the person while applying the technique.

People come to me discouraged and overwhelmed—their hopes and dreams abandoned. Early in our time together, I ask many detailed questions about how they would like life to change. What would you do during the day? Where would you live? What would your relationship to your family be like? What would you do in your spare time? What kind of social circle would you have? By getting detailed descriptions, I get concrete goals (eg, I want to go to school, argue less with my parents, spend more time with friends).

Almost always, working with the family is useful; sometimes it is absolutely necessary. What would be a good life for your child? How would it affect you?

Sometimes our dreams are big, perhaps even too extravagant; sometimes they are small and perhaps too cautious. But dreams always become more realistic and realizable when they are expressed. Sharing a dream and making it a treatment goal helps the person make a bigger investment in the treatment, and to take more responsibility for it. He becomes the driver and the therapist may sit in the back seat.

Because my first conversation is not just about symptoms and troubles, we start off on a basis of realistic hope and avoid a negative spiral dominated only by troubles. Problems have to be faced, but from a position of strength, not despair and helplessness.

Having a rounded view of the person’s problems and strengths enriches the therapeutic contact and creates a strong alliance.

Thanks, Ms Marell, for terrific advice. Some of the best natural therapists I have known have been ruined by psychotherapy training—becoming so preoccupied learning and implementing technique that they lost the healing warmth of their personalities.

Therapy should always be an exciting adventure, an intense meeting of hearts and minds. You can’t learn to be an effective therapist by reading a manual and applying it mechanically.

I would tell therapists I supervised never to apply what we discussed to their next session with the patient, lest they would always be a week behind. Therapy should be informed by technique, but not stultified by it.

See more at: http://www.psychiatrictimes.com/blogs/couch-crisis/magical-healing-power-caring-and-hope-psychotherapy?GUID=C523B8FD-3416-4DAC-8E3C-6E28DE36C515&rememberme=1&ts=16072015#sthash.2AOArvAW.dpuf

New study identifies potential new class of more rapidly acting antidepressant medications

On By A.P.In Depression, Medicine, Neuropsychiatric Disease, Psychiatry1 Comment

A new study by researchers at University of Maryland School of Medicine has identified promising compounds that could successfully treat depression in less than 24 hours while minimizing side effects. Although they have not yet been tested in people, the compounds could offer significant advantages over current antidepressant medications.

The research, led by Scott Thompson, PhD, Professor and Chair of the Department of Physiology at the University of Maryland School of Medicine (UM SOM), was published this month in the journal Neuropsychopharmacology.

“Our results open up a whole new class of potential antidepressant medications,” said Dr. Thompson. “We have evidence that these compounds can relieve the devastating symptoms of depression in less than one day, and can do so in a way that limits some of the key disadvantages of current approaches.”

Currently, most people with depression take medications that increase levels of the neurochemical serotonin in the brain. The most common of these drugs, such as Prozac and Lexapro, are selective serotonin reuptake inhibitors, or SSRIs. Unfortunately, SSRIs are effective in only a third of patients with depression. In addition, even when these drugs work, they typically take between three and eight weeks to relieve symptoms. As a result, patients often suffer for months before finding a medicine that makes them feel better. This is not only emotionally excruciating; in the case of patients who are suicidal, it can be deadly. Better treatments for depression are clearly needed.

Dr. Thompson and his team focused on another neurotransmitter besides serotonin, an inhibitory compound called GABA. Brain activity is determined by a balance of opposing excitatory and inhibitory communication between brain cells. Dr. Thompson and his team argue that in depression, excitatory messages in some brain regions are not strong enough. Because there is no safe way to directly strengthen excitatory communication, they examined a class of compounds that reduce the inhibitory messages sent via GABA. They predicted that these compounds would restore excitatory strength. These compounds, called GABA-NAMs, minimize unwanted side effects because they are precise: they work only in the parts of the brain that are essential for mood.

The researchers tested the compounds in rats that were subjected to chronic mild stress that caused the animals to act in ways that resemble human depression. Giving stressed rats GABA-NAMs successfully reversed experimental signs of a key symptom of depression, anhedonia, or the inability to feel pleasure. Remarkably, the beneficial effects of the compounds appeared within 24 hours – much faster than the multiple weeks needed for SSRIs to produce the same effects.

“These compounds produced the most dramatic effects in animal studies that we could have hoped for,” Dr. Thompson said. “It will now be tremendously exciting to find out whether they produce similar effects in depressed patients. If these compounds can quickly provide relief of the symptoms of human depression, such as suicidal thinking, it could revolutionize the way patients are treated.”

In tests on the rats’ brains, the researchers found that the compounds rapidly increased the strength of excitatory communication in regions that were weakened by stress and are thought to be weakened in human depression. No effects of the compound were detected in unstressed animals, raising hopes that they will not produce side effects in human patients.

“This work underscores the importance of basic research to our clinical future,” said Dean E. Albert Reece, MD, PhD, MBA, who is also the vice president for Medical Affairs, University of Maryland, and the John Z. and Akiko K. Bowers Distinguished Professor and Dean of the School of Medicine. “Dr. Thompson’s work lays the crucial groundwork to transform the treatment of depression and reduce the tragic loss of lives to suicide.”

http://www.news-medical.net/news/20150714/New-study-identifies-potential-antidepressant-medications-with-few-side-effects.aspx

Antidepressant Clinical Trials Exclude about 80% of People with Depression

On By A.P.In Depression, Neuropsychiatric Disease, PsychiatryLeave a comment

A provocative new study suggests that more than 80 percent of people with depression in the general population aren’t eligible for clinical trials of antidepressant drugs.

Researchers comment that at least five patients would need to be screened to enroll just one patient meeting the typical inclusion and exclusion criteria for antidepressant registration trials (ARTs).

Drs. Sheldon Preskorn and Matthew Macaluso of University of Kansas School of Medicine-Wichita and Dr. Madhukar Trivedi of Southwestern Medical School in Dallas led the study.

The investigation illuminates some major differences between patients with depression seen in everyday clinical practice and those enrolled in ARTs. This awareness is meaningful as ARTs commonly lead to FDA drug approval for depression medications.

The study appears in the Journal of Psychiatric Practice.

Antidepressant registration trials use certain inclusion and exclusion criteria to create a group of patients with similar characteristics. These criteria increase the chances of detecting true drug effects, while reducing “false signals” of safety problems or side effects.

For example, ARTs commonly exclude patients with other medical problems — if their illness worsened during the study, it might raise inaccurate safety concerns about the drug being studied.

To find out how these inclusion and exclusion criteria affect patient selection for ARTs, the researchers analyzed more than 4,000 patients from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study.

Funded by the National Institute of Mental Health, STAR*D was the largest and longest study of depression treatment ever conducted. To ensure that the “real world” population of patients with depression was represented, STAR*D used minimal exclusion criteria.

The researchers found that more than 82 percent of STAR*D patients would not be eligible for enrollment in current ARTs, based on a list of “usual” inclusion and exclusion criteria. Fourteen percent would be excluded on the basis of age alone–that’s because most ARTs exclude patients older than 65. Another 15 percent would be excluded because their depression was less severe than a commonly used cutoff point.

More than 20 percent of STAR*D patients would be excluded from ARTs because of a “clinically significant or unstable general medical condition.” Twenty-one percent of women would be excluded because they were not using birth control to prevent pregnancy during the study.

Because many ARTs use stricter criteria, the true exclusion rate is probably even higher, the authors note.

For example, more recent studies have used even higher severity thresholds for enrollment, which would eliminate more than 90 percent of the STAR*D population. The researchers also point out that all of the STAR*D patients had obviously agreed to participate in that research study — which is something many people with depression might be unwilling to do.

The researchers hope their work will help drug developers understand how inclusion and exclusion criteria may affect enrollment in ARTs, and help them in developing an appropriate recruitment plan and timeline.

“The timelines in most drug studies are unrealistically short and their recruitment plans are often woefully inadequate, resulting in studies that take longer than expected to complete and frequent budget overruns,” the researchers write.

Failure to consider the effort needed for ART recruitment might lead to lost revenue, delays in bringing a drug to market, or failure to develop a potentially effective medication.

The findings may also help to explain to healthcare practitioners why ARTs tend to overestimate the benefits of antidepressant treatment in “real world” patients with depression. “Obviously,” the researchers add, “the more patients who are excluded from the ARTs, the greater the chances that the results will not generalize to the routine clinical practice.”

http://psychcentral.com/news/2015/07/15/antidepressant-clinical-trials-exclude-many-people-with-depression/86887.html

Meet the Man Trying to Use Ayahuasca to Treat PTSD

On By A.P.In ayahuasca, Depression, Medicine, mental health, mental illness, Neuropsychiatric Disease, psychedelic, Psychiatry, psychology, psychotherapy, PTSDLeave a comment

Deep in the Amazon rainforest, a group of veterans chokes down a gritty, gut-wrenching shot of liquid absolution. They try to drink away their severe mental disturbances, but not the way you drink away your ex-girlfriend with a bottle of whiskey. They’re looking for a cure. Their leader: 27-year-old retired infantryman Ryan LeCompte. Their goal: to hallucinate away their terrible memories.

From a few fringe psychiatrists to veterans like LeCompte, there is a budding belief that extreme hallucination can save our brains from themselves. Several organizations, including the Multidisciplinary Association for Psychedelic Studies (MAPS), and adventurous doctors around the world test out psychedelics such as MDMA, psilocybin and ayahuasca for possible medical uses.

Ayahuasca is a devilish brew. It’s made of vines and roots found in the Amazon; drinking it equals a heavy psychedelic experience and profuse vomiting. “As the shapes and colors continued to move about, they sometimes converged to create the face of a woman, who of course I immediately labeled as Aya,” says an ayahuasca user on the underground drug website Erowid. Aya is known as the spirit or soul of the ayahuasca world. LeCompte described having kaleidoscope vision during his ayahuasca trip, and he even began to dance and went to look at leaves and other pieces of the nature around him at points.

Ryan LeCompte is a scruffy former Marine who, today, is studying at the eccentric Naropa University in Boulder. The school was founded by Tibetan Buddhist teacher and Oxford University scholar Chögyam Trungpa and includes schools such as the Jack Kerouac School of Disembodied Poetics. The beat poets used to flock to there. It’s a Buddhist-inspired school infamous for attracting people who are looking for an alternative education in an attractive location.

For his part, LeCompte didn’t ever face a PTSD diagnosis during his time in service. But he’s lucky, because many of his peers did. What he did experience still shook him. In 2008, while stationed in 8th and I Marine Barracks in Washington, D.C., LeCompte walked into the room of a good friend in his barracks one morning to find Sgt. Jorge Leon-Alcivar dead—a suicide. He was not the only Marine LeCompte encountered who would take his own life. At least 22 veterans kill themselves every day. Leon-Alcivar’s death was the final straw, and three years later LeCompte retired from the Marines to start fighting PTSD. He received his End of Active Service honorable discharge after four years in the Marines and didn’t look back.

LeCompte began traveling to the VA hospital in Birmingham, Alabama, where he was living, to learn what was ailing disturbed veterans and soldiers. He hung around in waiting rooms, cautiously approaching the soldiers, wheedling their stories out. But it didn’t take much persuasion; the men were “so beat,” he recalls, that they opened up to him instantly. This took course over several years, during his free time, while he did contract work building helicopters.

Soon, LeCompte had amassed the information from about 100 cases in Birmingham; Veterans spilled almost everything to him: their meds, their dosages, their choice of therapy. It all added up. Over and over again, he discovered his peers were taking the same types of medicines such Zoloft and Paxil, in the same dosages, 50 to 200mg of Zoloft a day or 20 to 60mg of Paxil a day were common, and with the same form of EMDR therapy. EMDR is a somatic therapy that follows eye movements and dream states.

LeCompte didn’t see anything wrong with the therapy. How about the drugs? Yeah, it’s probably the drugs. LeCompte’s complaints ring of an old story these days in American psychiatry: we’re too drugged up, we’re overdosed and overdiagnosed. It’s a complaint plenty of professionals agree with, but only a handful of psychiatrists are taking alternate routes. “There are some veterans who actually do respond to those meds, but it’s rare,” Dr. Sue Sisley, an expert on PTSD in veterans who has studied treating the illness with marijuana, told ATTN:. “The vets who respond to the standard FDA approved meds like Zoloft or Paxil is probably less than 10 percent. The rest come in looking like zombies.”

LeCompte had tried almost all the drugs they were offering, from “highly addictive anxiolytics like Klonopin, and … Prozac as an anti-depressant and Ambien for a sleep aid,” he said. “These different drugs sort of mixed together in a cocktail just as a recipe for disaster,” he said. He never tried to contact U.S. Veteran’s Affairs to inform them of these problems, because he didn’t think they would do anything about it. VA psychiatrists like Dr. Basimah Khulusi of Missouri have been fired for simply refusing to increase medication dosages that they didn’t think their patients needed shows the kind of system LeCompte was dealing with.

LeCompte looked into how these drugs work and found they’re just mind blockers, they’re not helping you deal with your problems. “Medications do not entirely eliminate symptoms but provide a symptom reduction and are sometimes more effective when used in conjunction with an ongoing program of trauma specific psychotherapy,” according to the VA website.

LeCompte looked at research from people like Julie D. Megler, watched videos of the academic conferences focusing on psychedelics called Psychedemia from Penn State and went on websites like Erowid to look at ayahuasca experiences people had posted to the site. What did he learn? “Something like ayahuasca or MDMA is used to bridge severed connections in the brain that trauma plays a big part in creating,” he said.

“Ayahuasca opens the limbic pathways of the brain to affect the emotional core of the trauma in a way similar to affective psychotherapy for trauma, and also impacts higher cortical areas … to allow the patient to assign a new context to their trauma,” wrote brain experts J. L. Nielson and J. D. Megler, in the book The Therapeutic Use of Ayahuasca.

Soon, LeCompte started having conversations with veterans and began informing people of the possible benefits of ayahuasca, wondering if anyone else was daring enough to start considering the idea of drinking a shot of psychedelics for their PTSD. LeCompte had never tried ayahuasca, but he was willing to try anything to help his comrades. Eventually he heard of an ayahuasca retreat, the Phoenix Ayahuasca retreat in Peru, where he could test out his medicine.

It took him six months to do what any sane person would do before planning a group outing to South America to hallucinate in a forest together… he started a nonprofit. Its name? The Veterans for Entheogenic Therapy. Other vets started to find him; some were suicidal, exhausted by the daily challenge of deciding whether or not they wanted to be alive. He didn’t know them, but he felt he intimately understood – or at least sympathized with – their minds. He rounded up a trip: five other vets, and him. MAPS helped pay for two of the trips for veterans who couldn’t afford it, and the rest paid for themselves.

The prep was strangely regimented: LeCompte had to ensure the veterans were off their medication for a month leading up to the trip; anti-depressants plus ayahuasca equal a lethal mix. That task amounted to phone therapy and keeping a close eye on everyone: He called the guys every day, even their friends and family, to make sure the men had quit their pills, he said. But he made it work. The families may have thought the idea was strange, but LeCompte says none of them tried to stop their family members because of their knowledge that the drugs weren’t helping treat the PTSD symptoms, and they just wanted to help their family.

The veterans flew into Iquitos, Peru, from Lima – from Iquitos, they sat in a van all the way to the Amazon, winding past motorbikes and rickshaws “on back roads in the middle of bum fuck,” LeCompte says.

Then their lives collided and things got weird.

They were stationed for 10 days at Phoenix Ayahuasca. The camp was little more than a set of huts in the jungle, made from wood and leaves. They would drink the ayahuasca on ceremony nights and be led through their experience by the shaman, and they would stay in their personal huts on days off to reflect on their experiences alone.

LeCompte said the ayahuasca drink “tastes like shit.” The shaman leading the experience dressed in all white scrub-like clothes, like a nurse lost in the jungle. After you drink the brew, the shaman’s job is simply to observe. He diagnoses: Is anyone losing it? Some people have been known to begin convulsing. Is this the moment they need to hear a song that will send them burrowing into a different dimension? “I don’t know how he does it. It’s beyond my rational mind,” LeCompte said. “It” amounts to singing, blowing smoke on trippers’ faces and using instruments like a rattler to change their state of mind.

For his part, LeCompte only wanted two out of the four drink ceremonies, since they were so powerful. It certainly wasn’t about the PTSD for LeCompte; he was trying to get past his experiences of fallen friends and broken relationships. He says just returning home to family and friends from military service or an ayahuasca trip is a difficult experience of its own. “You’re a changed person and there’s no doubting or denying that.”

“Most people get a cut, and they put a bandaid on it,” he said. “These people have had these wounds for so long that they’ve become infected. The infection can’t be fought off with a bandaid.” LeCompte sees ayahuasca as an antibiotic, not a bandaid.

LeCompte is now planning to do an official study to look at how ayahuasca could treat PTSD, which will serve as his thesis for Naropa University. It is being sponsored by MAPS, and it will focus on 12 veterans with treatment resistant PTSD who will try using ayahuasca to treat it. The plan is to conduct the study over 10 days in early 2016. LeCompte is currently running an Indiegogo campaign to fund research and education around the medicinal use of ayahuasca.

http://www.stumbleupon.com/su/2KDuBh/:1EfXhqlsu:Y+0NYw4t/www.attn.com/stories/2301/semicolon-tattoo-mental-health