Treatment of Psychiatric Disorders
Report compiled by Glen O. Gabbard, M.D., Chairperson
May 6, 2008
A superb line-up of speakers described cutting-edge treatments at this symposium.
Dr. Steven Dubosvsky began with an overview of current and future treatments for non-Alzheimer’s dementia. He reviewed a number of treatments, including memantine, gingko biloba, cholinesterase inhibitors, SSRIs, clozapine, and selegiline. He stressed that the treatments must be tailored to the condition. The disorders covered were MS dementia, Parkinson’s disease, frontotemporal dementia, HIV-associated dementia, multi-infarct dementia and pointed out the cholinesterase inhibitors are best for everything but frontotemporal dementia, which they may make worse. Antipsychotic drugs can also be problematic.
Dr. Carol Tamminga’s presentation “Pharmacological and Psychological Treatments of Symptoms of Schizophrenia” addressed how treatment emphasis has shifted to component symptom complexes, such as psychosis, cognitive dysfunction, and negative symptoms. We use antipsychotic drugs for psychosis. We don’t have treatments for the latter two symptom complexes. Some antipsychotics make negative symptoms worse. She identified several putative molecular targets for treating cognition. She then reviewed the research designed to develop specific agents for each of these targets. Receptors discussed included the glutamate system, the nicotinic, muscarinic and dopaminergic receptors, and the GABA system. Glutamate is the primary excitatory system in the brain and GABA is the primary inhibitory system. The serotonin system was also discussed. Many experimental agents are currently under development that will soon be available for treatment of cognition. The current thinking is that it is important to combine these agents with cognitive exercises such as rewarding mental work, which is available on the computer and done 3 times per week for 60-90 minutes. Social outcomes appear to improve with cognitive remediation.
The third speaker addressed “Autistic learning disabilities and autistic learning styles: a framework for developing individualized treatment plans for autistic spectrum disorders," and categorized a number of the problems that people with autism have and demonstrated how to tailor treatment approaches to the problems. We don’t have good treatments yet for these conditions. Motivation and intellectual ability are important in determining the outcome of treatment. She stressed that people with ASDs can have a verbal age at one level and a performance age at a much older level. He may do well with computers but can’t deal with the social aspects of the workplace. You must help families learn that at some point the person’s life is his own and not the parents. Finding ways to motivate the patient is extremely important. It helps motivate the patient if you understand routines, interests, and their capacity for social appraisal.
The symposium then turned to the topic of borderline personality disorder. John Gunderson provided an update on the treatment of BPD. He noted that treatments are now much more evidence-based than in the past. He stressed that these patients are much more treatable than once thought. He focused on psychoeducation, evidence-based psychotherapy, and medication. He discussed dialectical behavior therapy, schema-focused therapy, mentalization-based therapy, and transference-focused therapy. He noted shared characterstics: structure, coherent theory, active, focus on feelings, and countertransference recognition and management. In all 4 models what is regarded as most central in theory may not be most central in practice. The actual effect size of SSRIs is small, and current guidelines attribute more efficacy to atypicals. Remission of depression doesn’t change BPD. Treating BPD does improve depression. Improving lives does better than meds in terms of helping the patient.
The symposium concluded with Dr. Michael Thase. He focused on psychotherapy of depression and noted that most patients with depression have only a partial response to antidepressants. The average person does not want to take an antidepressant. When primary care practitioners ask a patient they prefer therapy over antidepressants 2:1. He covered empirically validated therapies, including CBT, behavioral activation, IPT, and psychodynamic therapy. The latter has just crossed over into one of the empirically validated therapies recently because of the heroic efforts of a group of Dutch researchers. In STAR*D, switching to CBT from citalopram and augmenting citalopram with CBT were studied. One major study recently of Behavior Activation therapy showed that it worked, and in some analyses it did better than CBT. Dynamic therapy studies include two from De Jonghe in 2001 and 2004. Two others are in press—a meta-analysis of three studies showed that combination did better than short term dynamic, which did better than medication.