Notable Links and Miscellania - Dec 29, 2024
A recap of some of my academic publications in 2024 that will be of interest to readers of Psychiatry at the Margins
Aftab A, Banicki K, Ruffalo M, and Frances A. Psychiatric Diagnosis: A Clinical Guide to Navigating Diagnostic Pluralism. Journal of Nervous and Mental Disease. 2024.
Stein DJ, Nielsen K, Hartford A, Gagné‐Julien AM, Glackin S, Friston K, Maj M, Zachar P, Aftab A. Philosophy of psychiatry: theoretical advances and clinical implications. World Psychiatry. 2024.
Aftab A, Sadler JZ, Kious BM, Waterman GS. Conceptual competence in psychiatric training: building a culture of conceptual inquiry. BJPsych Bulletin. 2024.
Aftab A. Making sense of the literature on antipsychotics and long-term functioning: taking natural history and personalization seriously. Psychological Medicine. 2024: doi:10.1017/S003329172400312X
My article in Psyche for general readers: What a psychiatric diagnosis means – and what it doesn’t mean
My first book, “Conversations in Critical Psychiatry,” an academic volume from Oxford University Press, is an edited selection of interviews published in the Psychiatric Times from 2019 to 2022, updated with new and previously unpublished material, including a foreword by Sir Robin Murray, a detailed introductory essay ‘Psychiatry and the Critical Landscape,’ and my own interview.
Order online at OUP academic with promotion code AMPROMD9 for a 30% discount.
Happy 2025!
Outline of the post
The material is organized into the following sections:
Substack links
Psychiatry, clinical psychology, and the practice of mental health
Neuroscience
Psychiatric neuroscience
Philosophy
Clinical trials, data analyses, and systematic reviews
Science, medicine, and meta-science
Substack
David Brooks gave the essay ‘Why do people believe true things?’ by
a ‘Sidney award’ in his column at the New York Times. It’s also one of my favorite pieces by Dan, and I highly recommend it if you haven’t already read it.Exciting things are happening in the development arena of GLP-1s for addiction. See predictions for 2025 and beyond by
Scott Alexander (
) — Prison And Crime: Much More Than You Wanted To Know- — “It seems, well, notable that nearly all of the American founders died thinking their experiment had failed.” — REVIEW: Fears of a Setting Sun, by Dennis C. Rasmussen
- — A Speculative Explanation of the Missing Heritability Problem — parts one, two, three
- — 2275 pharmacies have closed so far in 2024. My profession is really struggling. We need help.
- discusses Cobenfy, a combination of xanomeline and trospium chloride, approved in late 2024 for the treatment of schizophrenia.
Psychiatry, clinical psychology, and the practice of mental health
Riadh Abed, Adam Hunt, and Paul St John-Smith in the British Journal of Psychiatry. Evolutionary theory can advance and revitalise the biopsychosocial model
Financial Times — How a small Italian city became a model for mental health care
“Anyone experiencing a mental health problem has the right to seek help from one of the community mental health centres without a doctor’s referral, a low barrier to treatment that means problems can often be addressed before they escalate. “The elimination of bureaucratic hurdles is part of the reason for the [lack of] waiting lists,” she adds.
The feat is all the more striking because just 3.5 percent of Italy’s healthcare budget is allocated to mental health, one of the lowest figures among high-income countries.
One admirer of the Trieste model is Kerry Morrison, head of Heart Forward, a Los Angeles-based mental health charity who has visited the city multiple times. “They do all their investment ‘upstream’, starting at the time of a diagnosis [and] having a strong belief in recovery,” she says.
In the US, in contrast, the focus is on “crisis stabilisation” and there is very little community support. “So you have crisis upon crisis upon crisis . . . but we’re not investing in recovery that would help to prevent these longer-term financial impacts on our system,” she adds…
At the Maddalena community mental health centre in a working-class suburb of Trieste, Bonavigo describes a recent callout that typifies the approach. A man got in touch, alarmed that his mother, in her eighties and living with bipolar disorder, was in a manic state and had scarcely slept for days.
Bonavigo, accompanied by a nurse who had known the woman for many years, went to her apartment and spent two hours persuading her to take her medication. They then agreed on a regime of daily home visits that respected her determination not to be taken to hospital; she had suffered a broken nose in an accidental fall during an earlier visit.
“Part of our job is to take some risks,” Bonavigo says, a philosophy that surfaces several times in conversations with staff in the mental health system. “If in a situation, I can choose between two or three options, I should try to do what the person prefers.”
[See also: an introduction to the Trieste model by Vincenzo Passante in a guest post for Psychiatry at the Margins]
Lucy Foulkes in the British Journal of Psychiatry. The problem with mental health awareness.
“What ties these concerns together is one single, overarching problem: we do not have clear evidence about the impact of mental health awareness efforts. It may be that these efforts are merely a waste of time or that they are actively harmful. Or it may be that despite the above concerns, there is still a net gain that makes the efforts worthwhile. At present we do not know, because there has been limited empirical research on this topic. While mental health awareness efforts continue to proliferate, as a field we must consider what can be done to answer this urgent question.”
Danica E. Johnson & Joshua D. Rosenblat in Nature Mental Health. Psilocybin-assisted psychotherapy as an ‘anti-distressant’ with multidimensional properties
“Although PAP [Psilocynin-assisted psychotherapy] is currently best known for its antidepressant effects, it could potentially be reconceptualized as an anti-distressant (that is, a treatment that reduces distress across disparate disorders) if it is found to have generalized beneficial across different medical and psychiatric disorders.”
I don’t disagree with that, but it is important to recognize that by this logic, existing antidepressants such as SSRIs are already anti-distressants.
[See: How Antidepressants Work]
The American Psychiatric Association has released its latest practice guideline for the treatment of patients with borderline personality disorder. A notable feature is that unlike popular erroneous understanding that dialectical behavioral therapy (DBT) is the psychotherapy of choice for BPD, the APA guideline notes that no psychotherapy modality emerges as a particular winner:
“Although a number of structured approaches to psychotherapy that target BPD are superior to treatment-as-usual or wait-list control conditions, there is no clear evidence that any specific structured approaches to psychotherapy of BPD have significantly superior outcomes to other BPD-focused structured psychotherapeutic modalities in either adults or adolescents.”
Dialectical behavior therapy (DBT), dynamic deconstructive psychotherapy (DDP), mentalization-based treatment (MBT), schema-focused therapy (SFT), systems training for emotional predictability and problem solving (STEPPS), transference-focused psychotherapy (TFP), and good psychiatric management (GPM) are all discussed as possible structured approaches.
Max Fink (aged 101!) in the Journal of ECT. Flurothyl Inhalation Therapy: Resurrecting an Alternative to Electricity Induced Seizures
Natalia Tesli & Anja Vaskinn in the British Journal of Psychiatry. Violence and schizophrenia: let us take a deep breath and gain a meta-perspective.
“Perhaps the best approach to dispel the stigma is an in-depth understanding of the association between violence and schizophrenia while acknowledging the limitations of scientific inquiry. This endeavour requires an ongoing, balanced discourse supported by rigorous longitudinal quantitative and qualitative research that confronts rather than shies away from the complexities of these issues.”
[See also:
’s discussion of the association between schizophrenia and violence]Nicholas Fabiano, David Puder, and Brendon Stubbs. The Evidence Is Clear, Exercise Is Not Better Than Antidepressants or Therapy: It Is Crucial to Communicate Science Honestly
Brian Barnett et al. in Psychopharmacology. Practical considerations in the establishment of psychedelic research programs.
“Investigators planning to conduct psychedelic research should cultivate broad institutional support early. Challenges related to securing funding, obtaining approval for an Investigational New Drug application from the Food and Drug Administration, clinical grade drug sourcing, obtaining a Schedule I researcher registration from the Drug Enforcement Administration and an equivalent state license (if required), preparing spaces for treatment and study drug storage, managing controlled substance inventory, engaging the local community, and other issues should be anticipated.”
Carl Zhou, David Puder, and Nicholas Fabiano. How to prescribe physical activity for depression.
Hel Spandler in Mad in America. “What Matters to You?” – An Antidote to “What’s Wrong” and “What Happened”
“The idea of ‘what matters to you?’ places survivor knowledge at the centre and creates space for a range of responses and possibilities. It also acknowledges that what matters to us might shift over time. It allows for the possibility that ‘what happened’ is really important to us, and we may want access to support to help us address that. However, it doesn’t assume this is always the case — whether we’ve been traumatised or not.”
Zachary Rosenthal et al. bioRxiv. Electroconvulsive therapy generates a hidden wave after seizure.
“Electroconvulsive therapy (ECT) is a fast-acting, highly effective, and safe treatment for medication-resistant depression. Historically, the clinical benefits of ECT have been attributed to generating a controlled seizure; however, the underlying neurobiology is understudied and remains largely unresolved. Using optical neuroimaging to probe neural activity and hemodynamics in a mouse model of ECT, we demonstrated that a second brain event follows seizure: cortical spreading depolarization (CSD). We further found that ECT stimulation pulse parameters and electrode configuration directly shaped the wave dynamics of seizure and subsequent CSD. To translate these findings to human patients, we tested for the presence of hemodynamic signatures of post-ictal CSD using non-invasive diffuse optical monitoring of cerebral blood flow and oxygenation during routine ECT treatments. We found evidence that humans generate hyperemic waves after ECT seizure which are highly consistent with CSD. These results challenge a long-held assumption that seizure is the primary outcome of ECT and point to new opportunities for optimizing ECT stimulation parameters to precisely modulate brain activity and treatment outcomes.” (my emphasis)
Broadening Understanding of Individual Choices About Psychiatric Medication Use in Psychiatric Rehabilitation. David Roe and Helene Speyer introduce a special issue of Psychiatric Rehabilitation Journal:
“Most individuals in recovery are likely to attempt discontinuing their prescribed medication at least once. The collection of articles in this special issue uses research with quantitative and qualitative methods, reviews of the literature, conceptualization of theory, and first-person accounts from various perspectives to begin to shift the field of psychiatric rehabilitation from a narrow focus on symptom reduction and a fear-driven emphasis on medication adherence to a new perspective in which dilemmas and strong feelings about medication use are commonplace.”
[See also: Helene Speyer’s guest post for Psychiatry at the Margins — Practicing Psychiatry in the Third Space]
Neuroscience
Jieyu Zheng & Markus Meister in Neuron. The unbearable slowness of being: Why do we live at 10 bits/s?
“This article is about the neural conundrum behind the slowness of human behavior. The information throughput of a human being is about 10 bits/s. In comparison, our sensory systems gather data at ~10^9 bits/s. The stark contrast between these numbers remains unexplained and touches on fundamental aspects of brain function: what neural substrate sets this speed limit on the pace of our existence? Why does the brain need billions of neurons to process 10 bits/s? Why can we only think about one thing at a time? The brain seems to operate in two distinct modes: the “outer” brain handles fast high-dimensional sensory and motor signals, whereas the “inner” brain processes the reduced few bits needed to control behavior. Plausible explanations exist for the large neuron numbers in the outer brain, but not for the inner brain, and we propose new research directions to remedy this.”
[See discussion of this paper in the Scientific American by Rachel Nuwer: The Unbelievable Slowness of Thinking]