Current Psychiatry

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.

A large percentage of psychiatrists practicing today are Boomers, and have experienced the tumultuous change in their profession since the end of World War II. At a recent Grand Rounds presentation in the Department of Neurology & Psychiatry at Saint Louis University, participants examined major changes and paradigm shifts that have reshaped psychiatry since 1946. The audience, which included me, contributed historical observations to the list of those changes and shifts, which I’ve classified here for your ben­efit, whether or not you are a Boomer.

Medical advances
Consider these discoveries and developments:
   • Penicillin in 1947, which led to a reduction in cases of psychosis caused by tertiary syphilis, a disease that accounted for 10% to 15% of state hos­pital admissions.
   • Lithium in 1948, the first pharma­ceutical treatment for mania.
   • Chlorpromazine, the first anti­psychotic drug, in 1952, launching the psychopharmacology era and ending lifetime institutional sequestration as the only “treatment” for serious mental disorders.
   • Monoamine oxidase inhibitors in 1959, from observations that iproniazid, a drug used in tuberculosis sanitariums, improved the mood of tuberculosis patients. This was the first pharmaco­therapy for depression, which had been treated with electroconvulsive therapy (ECT), developed in the 1930s.
   • Tricyclic antidepressants, starting with imipramine in the late 1950s, dur­ing attempts to synthesize additional phenothiazine antipsychotics.
   • Diazepam, introduced in 1963 for its anti-anxiety effects, became the most widely used drug in the world over the next 2 decades.
   • Pre-frontal lobotomy to treat severe psychiatric disorders. The neurosurgeon-inventor of this so-called medical advance won the 1949 Nobel Prize for Medicine or Physiology. The procedure was rap­idly discredited after the development of antipsychotic drugs.
   • Fluoxetine, the first selective sero­tonin reuptake inhibitor, in 1987, revo­lutionized the treatment of depression, especially in primary care settings.
   • Clozapine, as an effective treat­ment for refractory and suicidal schizophrenia, and the spawning of second-generation antipsychotics. These newer agents shifted focus from neurologic adverse effects (extrapy­ramidal symptoms, tardive dyskinesia) to cardio-metabolic side effects (obesity, diabetes, dyslipidemia, and hypertension).
 

Changes to the landscape of health care
Three noteworthy developments made the list:
   • The Community Mental Health Act of 1963, signed into law by President John F. Kennedy, revolu­tionized psychiatric care by shifting delivery of care from inpatient, hospital-based facilities to outpatient, clinic-based centers. There are now close to 800 community mental health centers in the United States, where care is dominated by non-physician mental health providers—in contrast to the era of state hospitals, during which phy­sicians and nurses provided care for mentally ill patients.
   • Deinstitutionalization. This move-ment gathered momentum in the 1970s and 1980s, leading to clos­ing of the majority of state hospitals, with tragic consequences for the seri­ously mentally ill—including early demise, homelessness, substance abuse, and incarceration. In fact, the large percentage of mentally ill peo­ple in U.S. jails and prisons, instead of in a hospital, represents what has been labeled trans-institutionalization (see my March 2008 editorial, “Bring back the asylums?,” available at CurrentPsychiatry.com).
    • Managed care, emerging in the late 1980s and early 1990s, caused a seismic disturbance in the delivery of, and reimbursement for, psychiat­ric care. The result was a significant decline in access to, and quality of, care—especially the so-called carve-out model that reduced payment for psychiatric care even more drastically than for general medical care. Under managed care, the priority became saving money, rather than saving lives. Average hospital stay for patients who had a psychiatric disorder, which was years in the pre-pharmacotherapy era, and weeks or months after that, shrunk to a few days under managed care.

Changes in professional direction
Two major shifts in the complexion of the specialty were identified:
   • The decline of psychoanalysis, which had dominated psychiatry for decades (the 1940s through the 1970s), was a major shift in the conceptual­ization, training, and delivery of care in psychiatry. The rise of biological psychiatry and the medical model of psychiatric brain disorders, as well as the emergence of evidence-based (and briefer) psychotherapies (eg, cognitive-behavioral therapy, dialectical behav­ior therapy, and interpersonal therapy), gradually replaced the Freudian model of mental illness.

As a result, it became no longer nec­essary to be a certified psychoanalyst to be named chair of a department of psy­chiatry. The impact of this change on psychiatric training has been profound, because medical management by psy­chiatrists superseded psychotherapy— given the brief hospitalization that is required and the diminishing coverage for psychotherapy by insurers.

   • Delegation of psychosocial treatments to non-psychiatrists. The unintended consequences of psychia­trists’ change of focus to 1) consulta­tion on medical/surgical patients and 2) the medical evaluation, diagnosis, and pharmacotherapy of mental dis­orders led to the so-called “dual treat­ment model” for the most seriously mentally ill patients: The physician provides medical management and non-physician mental health profes­sionals provide counseling, psychoso­cial therapy, and rehabilitation.

Disruptive breakthroughs
Several are notable:
   • National Institute of Mental Health (NIMH). Establishment of NIMH in April 1949 was a major step toward funding research into psychiatric disorders. Billions of dollars have been invested to gen­erate knowledge about the causes, treatment, course, and prevention of mental illness. No other coun­try has spent as much on psychi­atric research. It would have been nearly impossible to discover what we know today without the work of NIMH.
   • Neuroscience. The meteoric rise of neuroscience from the 1960s to the present has had a dramatic effect, transforming old psychiatry and the study and therapy of the mind to a focus on the brain-mind continuum and the prospects of brain repair and neuroplasticity. Psychiatry is now regarded as a clin­ical neuroscience specialty of brain disorders that manifest as changes in thought, affect, mood, cognition, and behavior.
   • Brain imaging. Techniques developed since the 1970s—the veritable alphabet soup of CT, PET, SPECT, MRI, MRS, fMRI, and DTI— has revolutionized understanding of brain structure and function in all psychiatric disorders but especially in psychotic and mood disorders.
   • Molecular genetics. Advances over the past 2 decades have shed unprecedented light on the complex genetics of psychiatric disorders. It is becoming apparent that most psychiatric disorders are caused via gene-by-environment interaction; etiology is therefore a consequence of genetic and non-genetic variables. Risk genes, copy number variants, and de novo mutations are being discovered almost weekly, and progress in epigenetics holds prom­ise for preventing medical disorders, including psychiatric illness.
    • Neuromodulation. Advances represent an important paradigm shift, from pharmacotherapy to brain stimulation. Several tech­niques have been approved by the FDA, including transcranial mag­netic stimulation, vagus nerve stim­ulation, and deep brain stimulation, to supplement, and perhaps eventu­ally supplant, ECT.

Legal intrusiveness
No other medical specialty has been subject to laws governing clini­cal practice as psychiatry has been. Progressive intrusion of laws (osten­sibly, enacted to protect the civil rights of “the disabled”) ends up hurting patients who refuse admis­sion and then often harm them­selves or others or decline urgent treatment, which can be associated with loss of brain tissue in acute psychotic, manic, and depressed states. No legal shackles apply to treating unconscious stroke patients, delirious geriatric patients, or semi­conscious myocardial infarction patients when they are admitted to a hospital.

Distortions of the anti-psychiatry movement
The antipsychiatry movement pre­ceded the Baby Boomer era by a cen­tury but has continued unabated. The movement gained momentum and became more defamatory after release of the movie One Flew Over the Cuckoo’s Nest in 1975, which por­trayed psychiatry in a purely nega­tive light. Despite progress in public understanding of psychiatry, and tangible improvements in practice, the stigma of mental illness per­sists. Media portrayals, including motion pictures, continue to distort the good that psychiatrists do for their patients.

Gender and sexuality
   • Gender distribution of psy­chiatrists. A major shift occurred over the past 7 decades, reflecting the same pattern that has been docu­mented in other medical specialties. At least one-half of psychiatry resi­dents are now women—a welcome change from the pre-1946 era, when nearly all psychiatrists were men. This demographic transformation has had an impact on the dynamics of psychiatric practice.
    • Acceptance and depatholo­gization of homosexuality. Until 1974, homosexuality was considered a psychiatric disorder, and many homosexual persons sought treat­ment. That year, membership of the American Psychiatric Association voted to remove homosexual­ity from DSM-II and to no longer regard it as a behavioral abnormal­ity. This was a huge step toward de-pathologizing same-sex orienta­tion and love, and might have been the major impetus for the progres­sive social acceptance of gay, lesbian, and transgendered people over the past 4 decades.

The DSM paradigm shift in psychiatric diagnosis
   • DSM-III. Perhaps the most radi­cal change in the diagnostic criteria of psychiatric disorders occurred in 1980, with introduction of DSM-III to replace DSM-I and DSM-II, which were absurdly vague, unreliable, and with poor validity.

The move toward more opera­tional and reliable diagnostic require­ments began with the Research Diagnostic Criteria, developed by the Department of Psychiatry at Washington University in St. Louis. DSM-III represented a complete par­adigm shift in psychiatric diagnosis. Subsequent editions maintained the same methodology, with relatively modest changes. The field expects continued evolution in DSM diag­nostic criteria, including the future inclusion of biomarkers, based on sound, controlled studies.
   • Recognizing PTSD. Develop-ment of posttraumatic stress disor­der (PTSD) as a diagnostic entity, and its inclusion in DSM-III, were major changes in psychiatric nosol­ogy. At last, the old terms—shell shock, battle fatigue, neurasthe­nia—were legitimized as a recogniz­able syndrome secondary to major life trauma, including war and rape. That legitimacy has instigated sub­stantial clinical and research interest in identifying how serious psycho­pathology can be triggered by life events.

Pharmaceutical industry debacle
Few industries have fallen so far from grace in the eyes of psychiatric profes­sionals and the public as the manufac­turers of psychotropic drugs.

At the dawn of the psychophar­macology era (the 1950s, 1960s, and 1970s) pharmaceutical companies were respected and regarded by phy­sicians and patients as a vital partner in health care for their discovery and development of medications to treat psychiatric disorders. That image was tarnished in the 1990s, however, with the approval and release of several atypical antipsychotics. Cutthroat competition, questionable publication methods, concealment of negative findings, and excessive spending on marketing, including FDA-approved educational programs for clinicians on efficacy, safety, and dosing, all con­tributed to escalating cynicism about the industry. Academic faculty who received research grants to conduct FDA-required clinical trials of new agents were painted with the same brush.

Disclosure of potential conflict of interest became a mandatory proce­dure at universities and for NIMH grant applicants and journal pub­lishers. Class-action lawsuits against companies that manufacture second-generation antipsychotics—filed for lack of transparency about metabolic side effects—exacerbated the inten­sity of criticism and condemnation.

Although new drug develop­ment has become measurably more rigorous and ethical because of self-regulation, combined with vigorous government scrutiny and regulation, demonization of the pharmaceuti­cal industry remains unabated. That might be the reason why several major pharmaceutical companies have abandoned research and devel­opment of psychotropic drugs. That is likely to impede progress in psy­chopharmacotherapeutics; after all, no other private or government entity develops drugs for patients who have a psychiatric illness. The need for such agents is great: There is no FDA-indicated drug for the majority of DSM-5 diagnoses.

We entrust the future to next generations
Momentous events have transformed psychiatry during the lifespan of Baby Boomers like me and many of you. Because the cohort of 80 million Baby Boomers has comprised a significant percentage of the nation’s scientists, media representatives, members of the American Psychiatric Association, academicians, and community lead­ers over the past few decades, it is conceivable that the Baby Boomer generation helped trigger most of the transformative changes in psychiatry we have seen over the past 70 years.

I can only wonder: What direc­tion will psychiatry take in the age of Generation X, Generation Y, and the Millennials? Only this is certain: Psychiatry will continue to evolve— long after Baby Boomers are gone.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.

Frontotemporal dementia (FTD) is a neu­rologic disease that affects the frontal and the temporal lobes of the cerebral cortex.¹ This disorder is observed most often in people between age 45 to 65, but also can manifest in younger or older persons.¹ The cause varies among a range of pathologies affecting the anterior portions of the brain.²

Presentations
FTD presents with changes in personality, social skills, ability to concentrate, motiva­tion, reasoning, and language abnormal­ity.³ Memory loss is less prominent in this condition compared with other dementias; therefore, identification may be a diagnos­tic challenge. FTD can be misdiagnosed as a psychiatric illness or not recognized because social symptoms dominate over cognitive dysfunction. As the disease progresses, patients may become increasingly unable to plan or organize activities of daily living, behave appropriately, and react normally in social interactions.¹

FTD has 3 diagnostic variants^1-4:

Behavioral variant. Known as Pick dis­ease or the “frontal variant,”^1,2 this type of FTD manifests as changes in personality, improper behavior in social settings, per­sonal neglect, or impulsivity, such as shop­lifting or hypersexuality.

Primary progressive aphasia. Two types of language dysfunction are observed in FTD:
   • Semantic dementia (SD)³: Left-sided SD presents with “meaningless speech” or “word substitutions” (eg, “chair” instead of “table”). Right-sided SD, however, is char­acterized by forgetting the faces of familiar people or objects.
   • Primary nonfluent aphasia³: Language fluency is compromised. Persons with such language dysfunction cannot produce words easily, and their speech is stumbling and nonfluent.

FTD with motor neuron disease.⁴ The most common type of motor neuron dis­ease associated with FTD is amyotrophic lateral sclerosis. Afflicted patients exhibit muscle weakness, spasms, and rigidity. This leads to difficulty in swallowing or breathing because the diaphragm and pharynx are paralyzed. Other diseases associated with FTD include corticobasal degeneration and progressive supranu­clear palsy.

Diagnosis
In DSM-5, FTD has been renamed “fronto­temporal lobar degeneration” under the cat­egory of “Major and Mild Neurocognitive Disorders.”⁵ The workup begins with a his­tory, physical examination, and mental sta­tus assessment. Physical signs can include frontal-release, primitive reflexes. Early in the disease course, a palmomental reflex often is observed; later, as disease progress, the rooting reflex or palmar grasp may become apparent.^1,5

Diagnosing FTD requires recognizing its symptoms and ruling out conditions such as Alzheimer’s disease, depression, and schizophrenia.⁶ Laboratory studies may help identify other conditions. Brain imaging, such as MRI, can depict fronto­temporal pathology and rule in or exclude other diseases.^3,5

Psychometric testing can evaluate mem­ory or cognitive ability, which might be unremarkable during the initial phases of FTD.⁴ Further psychological assessments may provide objective verification of frontal lobe deficiencies in social skills or activities of daily living.³ Positron emission tomogra­phy and single-photon emission computed tomography may demonstrate areas of decreased activity or hypoperfusion in fron­tal and temporal lobes.⁷

Interventions
Treatment of FTD is limited to symp­tomatic therapy⁸; there are no specific, approved countermeasures available. Comorbid conditions, such as diabetes mellitus or hypertension, should be treated medically. Social interventions such as day care, increased supervision, and emotional support from the family can be effective adjuvants.²

Disclosures
The authors report no financial relationship whose products are mentioned in this article or with manufacturers of competing products.

CASE Alien thoughts
Mr. C, age 23, is admitted to an intermediate-security facility because of unmanageable aggression. He is not charged with a crime and his legal status is admission by guardian. He is taking haloperidol decanoate, 300 mg IM every 28 days, and divalproex sodium, 1500 mg/d, but he continues to experience auditory hallucina­tions and the delusion that he is an alien.

Mr. C is given a primary diagnosis of chronic undifferentiated schizophrenia. He is started on risperidone tablets, 3 mg/d, and then switched to risperidone orally disintegrating tablets, titrated to 8 mg/d, to ensure compliance. Later, he receives separate trials of high-dose que­tiapine (up to 1200 mg/d) and olanzapine orally disintegrating tablets (up to 30 mg/d). Lithium, 1200 mg/d, sertraline, 100 mg/d, and long-acting propranolol, 120 mg/d, were added at various periods of his treatment.

He continues to experience hallucinations and delusions, is intermittently aggressive, is not engaged in the treatment program, and needs prompting for basic hygiene. Several times, we discuss with Mr. C using clozap­ine, but he refuses, mainly because of weekly blood draws.

How would you proceed with Mr. C’s care?
a) consider electroconvulsive therapy
b) order aripiprazole and an omega-3 fish oil supplement
c) consider involuntary clozapine therapy and lab testing

The author’s observations
Schizophrenia remains a chronic and often refractory illness. Patients suffer from intru­sive hallucinations; social and self-care defi­cits; cognitive impairment; and increased risk of violence, suicide, and premature death from medical causes. Pharmacotherapy is the mainstay of treatment, supplemented by individual and group therapies, psycho­social rehabilitation, housing assistance, and income support. Antipsychotics are funda­mental and clozapine has been established as the most effective antipsychotic in the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study,¹ but it remains underutilized.²

In 2008, clozapine accounted for only 4.4% of antipsychotic prescriptions in the United States.³ In our state forensic facility, only 10% of patients on an antipsychotic received clozapine in 2011. Despite the CATIE trial, there were no significant increases in clo­zapine prescribing after the results were published⁴ and patients often experience a substantial delay before clozapine is ini­tiated.⁵ In the last several years, we have looked at methods to increase clozapine use in our hospital and have described some of our experiences. Despite enthusiasm for, and good experi­ence with, clozapine, barriers limit the use of this medication (Table 1). One signifi­cant barrier is patient acceptance. Although most of our patients taking an atypical anti­psychotic will accept a blood draws every 6 months for metabolic monitoring, many will reject clozapine because of the initial weekly blood draw. Other patients will reject a trial of clozapine because of fears of serious adverse reactions.

Drug Brand Names
Aripiprazole • Abilify                            
Polyethylene glycol • MiraLax
Clozapine • Clozaril, FazaClo                
ropranolol • Inderal LA
Desmopressin • DDAVP                     
Quetiapine • Seroquel
Divalproex sodium • Depakote             
Risperidone • Risperdal
Haloperidol • Haldol                            
Sertraline • Zoloft
Lithium • Eskalith, Lithobid   
Terazosin • Hytrin
Olanzapine • Zyprexa            
Topiramate • Topamax

CASE Alien thoughts
Mr. C, age 23, is admitted to an intermediate-security facility because of unmanageable aggression. He is not charged with a crime and his legal status is admission by guardian. He is taking haloperidol decanoate, 300 mg IM every 28 days, and divalproex sodium, 1500 mg/d, but he continues to experience auditory hallucina­tions and the delusion that he is an alien.

Mr. C is given a primary diagnosis of chronic undifferentiated schizophrenia. He is started on risperidone tablets, 3 mg/d, and then switched to risperidone orally disintegrating tablets, titrated to 8 mg/d, to ensure compliance. Later, he receives separate trials of high-dose que­tiapine (up to 1200 mg/d) and olanzapine orally disintegrating tablets (up to 30 mg/d). Lithium, 1200 mg/d, sertraline, 100 mg/d, and long-acting propranolol, 120 mg/d, were added at various periods of his treatment.

He continues to experience hallucinations and delusions, is intermittently aggressive, is not engaged in the treatment program, and needs prompting for basic hygiene. Several times, we discuss with Mr. C using clozap­ine, but he refuses, mainly because of weekly blood draws.

How would you proceed with Mr. C’s care?
a) consider electroconvulsive therapy
b) order aripiprazole and an omega-3 fish oil supplement
c) consider involuntary clozapine therapy and lab testing

The author’s observations
Schizophrenia remains a chronic and often refractory illness. Patients suffer from intru­sive hallucinations; social and self-care defi­cits; cognitive impairment; and increased risk of violence, suicide, and premature death from medical causes. Pharmacotherapy is the mainstay of treatment, supplemented by individual and group therapies, psycho­social rehabilitation, housing assistance, and income support. Antipsychotics are funda­mental and clozapine has been established as the most effective antipsychotic in the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study,¹ but it remains underutilized.²

In 2008, clozapine accounted for only 4.4% of antipsychotic prescriptions in the United States.³ In our state forensic facility, only 10% of patients on an antipsychotic received clozapine in 2011. Despite the CATIE trial, there were no significant increases in clo­zapine prescribing after the results were published⁴ and patients often experience a substantial delay before clozapine is ini­tiated.⁵ In the last several years, we have looked at methods to increase clozapine use in our hospital and have described some of our experiences. Despite enthusiasm for, and good experi­ence with, clozapine, barriers limit the use of this medication (Table 1). One signifi­cant barrier is patient acceptance. Although most of our patients taking an atypical anti­psychotic will accept a blood draws every 6 months for metabolic monitoring, many will reject clozapine because of the initial weekly blood draw. Other patients will reject a trial of clozapine because of fears of serious adverse reactions.

Drug Brand Names
Aripiprazole • Abilify                            
Polyethylene glycol • MiraLax
Clozapine • Clozaril, FazaClo                
ropranolol • Inderal LA
Desmopressin • DDAVP                     
Quetiapine • Seroquel
Divalproex sodium • Depakote             
Risperidone • Risperdal
Haloperidol • Haldol                            
Sertraline • Zoloft
Lithium • Eskalith, Lithobid   
Terazosin • Hytrin
Olanzapine • Zyprexa            
Topiramate • Topamax

CASE Alien thoughts
Mr. C, age 23, is admitted to an intermediate-security facility because of unmanageable aggression. He is not charged with a crime and his legal status is admission by guardian. He is taking haloperidol decanoate, 300 mg IM every 28 days, and divalproex sodium, 1500 mg/d, but he continues to experience auditory hallucina­tions and the delusion that he is an alien.

Mr. C is given a primary diagnosis of chronic undifferentiated schizophrenia. He is started on risperidone tablets, 3 mg/d, and then switched to risperidone orally disintegrating tablets, titrated to 8 mg/d, to ensure compliance. Later, he receives separate trials of high-dose que­tiapine (up to 1200 mg/d) and olanzapine orally disintegrating tablets (up to 30 mg/d). Lithium, 1200 mg/d, sertraline, 100 mg/d, and long-acting propranolol, 120 mg/d, were added at various periods of his treatment.

He continues to experience hallucinations and delusions, is intermittently aggressive, is not engaged in the treatment program, and needs prompting for basic hygiene. Several times, we discuss with Mr. C using clozap­ine, but he refuses, mainly because of weekly blood draws.

How would you proceed with Mr. C’s care?
a) consider electroconvulsive therapy
b) order aripiprazole and an omega-3 fish oil supplement
c) consider involuntary clozapine therapy and lab testing

The author’s observations
Schizophrenia remains a chronic and often refractory illness. Patients suffer from intru­sive hallucinations; social and self-care defi­cits; cognitive impairment; and increased risk of violence, suicide, and premature death from medical causes. Pharmacotherapy is the mainstay of treatment, supplemented by individual and group therapies, psycho­social rehabilitation, housing assistance, and income support. Antipsychotics are funda­mental and clozapine has been established as the most effective antipsychotic in the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study,¹ but it remains underutilized.²

In 2008, clozapine accounted for only 4.4% of antipsychotic prescriptions in the United States.³ In our state forensic facility, only 10% of patients on an antipsychotic received clozapine in 2011. Despite the CATIE trial, there were no significant increases in clo­zapine prescribing after the results were published⁴ and patients often experience a substantial delay before clozapine is ini­tiated.⁵ In the last several years, we have looked at methods to increase clozapine use in our hospital and have described some of our experiences. Despite enthusiasm for, and good experi­ence with, clozapine, barriers limit the use of this medication (Table 1). One signifi­cant barrier is patient acceptance. Although most of our patients taking an atypical anti­psychotic will accept a blood draws every 6 months for metabolic monitoring, many will reject clozapine because of the initial weekly blood draw. Other patients will reject a trial of clozapine because of fears of serious adverse reactions.

Drug Brand Names
Aripiprazole • Abilify                            
Polyethylene glycol • MiraLax
Clozapine • Clozaril, FazaClo                
ropranolol • Inderal LA
Desmopressin • DDAVP                     
Quetiapine • Seroquel
Divalproex sodium • Depakote             
Risperidone • Risperdal
Haloperidol • Haldol                            
Sertraline • Zoloft
Lithium • Eskalith, Lithobid   
Terazosin • Hytrin
Olanzapine • Zyprexa            
Topiramate • Topamax

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Fewer than 20% of people seeking help for depression and anxiety disorders receive cognitive-behavioral therapy (CBT), the most established evidence-based psychother­apeutic treatment.¹ Efforts are being made to increase access to CBT,² but a substantial barrier remains: therapist training is a strong predictor of treatment outcome, and many therapists offering CBT services are not sufficiently trained to deliver multiple manual-based interventions with adequate fidelity to the model. Proposed solutions to this barrier include:
   • abbreviated versions of CBT training for practitioners in primary care and community settings
   • culturally adapted CBT training for community health workers³
   • Internet-based CBT and telemedicine (telephone and video conferencing)²
   • mobile phone applications that use text messaging, social support, and physiological monitoring as adjuncts to clinical practice or stand-alone interventions.⁴

New models of CBT also are emerging, including transdi­agnostic CBT and metacognitive approaches (mindfulness-based cognitive therapy and acceptance and commitment therapy), and several new foci for exposure therapy.

In light of these ongoing modulations, this article is intended to help clinicians make informed decisions about CBT when selecting treatment for patients with depressive and anxiety disorders (Box⁵ ). We review the evidence of CBT’s efficacy for acute-phase treatment and relapse pre­vention; explain the common elements considered essential to CBT practice; describe CBT adaptations for specific anxiety disorders; and provide an overview of recent advances in conceptual­izing and adapting CBT.

Efficacy for mood and anxiety disorders
Depression. Dozens of randomized con­trolled trials (RCT) and other studies support CBT’s efficacy in treating major depressive disorder (MDD). For acute treatment:
   • CBT is more effective in producing remission when compared with no treat­ment, treatment as usual, or nonspecific psychotherapy.
   • For mild to moderate depression, CBT is equivalent to antidepressant medi­cation in terms of response and remission rates.
   • Combining antidepressant therapy with CBT increases treatment adherence.⁶

Less well known may be that a success­ful response to CBT in the acute phase may have a protective effect against depression recurrences. A 2013 meta-analysis that totaled 506 individuals with depressive disorders found a trend toward signifi­cantly lower relapse rates when CBT was discontinued after acute therapy, com­pared with antidepressant therapy that continued beyond the acute phase.⁷ 

Anxiety. Among psychotherapies, CBT’s superior efficacy for anxiety disorders is well-established. CBT and its specific-disorder adaptations are considered first-line treatment.⁸

CBT’s essential elements
CBT focuses on distorted cognitions about the self, the world, and the future, and on behaviors that lead to or maintain symptoms.

Cognitive interventions seek to identify thoughts and beliefs that trigger emotional and behavioral reactions. A person with social anxiety disorder, for example, might believe that people will notice if he makes even a minor social mistake and then reject him, which will make him feel worthless. CBT can help him subject these beliefs to rational analysis and develop more adap­tive beliefs, such as: “It is not certain that I will behave so badly that people would notice, but if that happened, the likeli­hood of being outright rejected is probably low. If—in the worst-case scenario—I was rejected, I am not worthless; I’m just a fal­lible human being.” 

CBT’s behavioral component can be con­ceptualized as behavioral activation (BA), a structured approach to help the patient:
   • increase behaviors and experiences that are rewarding
   • overcome barriers to engaging in these new behaviors
   • and decrease behaviors that maintain symptoms.

BA can be a useful intervention for indi­viduals with depression characterized by lack of engagement or capacity for pleasurable experiences. During pregnancy and the postpartum period, for example, a woman undergoes physical, social, and environmental changes that might gradu­ally deprive her of sources of pleasure and other reinforcing activities. BA would focus on developing creative solutions to regain access to or create new opportuni­ties for rewarding experiences and to avoid behaviors (such as social withdrawal or physical activity restriction) that perpetuate depressed mood.

Common elements. Cognitive and behav­ioral interventions focus on problem solv­ing, individualized case conceptualization (Figure 1), and collaborative empiricism.⁹

Collaborative empiricism is the way in which the patient and therapist work together to continually refine this work­ing hypothesis. The pair works together to investigate the hypotheses and all aspects of the therapeutic relationship.

Although no specific technique defines CBT, a common practice is to educate a person about interrelationships between behaviors/activities, thoughts, and mood. A mood activity log (Figure 2) can illuminate links between moods and activities and be useful with targeting interventions. For a person with social anxiety, for example, a mood activity log could assist in developing a hierarchy of feared social situations and avoidance intensity. Systematic exposure therapy would follow, beginning with the least frightening/intense situation, accompa­nied by teaching new coping skills (such as relaxation strategies).

CBT adaptations for anxiety disorders
Elements of CBT have been adapted for a variety of anxiety disorders, based on specific symptoms and features (Table).^10-15

Panic disorder. Panic control treatment is considered the first-line intervention for panic disorder’s defining features: spontaneous panic attacks, worry about future occurrence of attacks, and perceived catastrophic consequences (such as heart attack, fainting).¹⁰ This CBT adaptation includes:
   • patient education about the nature of panic
   • breathing retraining to foster exposure to feared bodily sensations and avoided activities and places
   • cognitive restructuring of danger-related thoughts (such as “I’m going to faint,” or “It would be catastrophic if I did”).

Obsessive-compulsive disorder. Exposure and response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD).¹¹ In traditional therapist-guided ERP, patients expose themselves to perceived contaminants while refraining from inappropriate compulsive behaviors (such as hand washing).

Cognitive interventions also can be an effective treatment of obsessions, with­out patients having to engage in exposure to their horrific thoughts and images.¹⁶ Consider, for example, a new mother who upon seeing the kitchen knife has the intrusive thought, “What if I stabbed my baby?” Instead of the traditional exposure approach for OCD (ie, having her vividly imagine stabbing her baby until her anxiety level subsided), the cognitive intervention would be to educate her about the nor­malcy of intrusive thoughts, particularly in the postpartum period.

Generalized anxiety disorder. CBT for generalized anxiety disorder (GAD) targets patients’ overestimation of the likelihood of negative events and the belief that these events, should they occur, would be cata­strophic and render them unable to cope.¹²

Motivational interviewing (MI) appears to be a useful adjunct to precede traditional CBT, particularly for severe worriers.¹⁷ MI attempts to help individuals with GAD rec­ognize their ambivalence about giving up worry. This technique acknowledges and validates perceived benefits of worry (eg, “It helps me prepare for the worst, so I won’t be emotionally devastated if it happens”), but also explores how worry is destructive.

Emerging CBT models for anxiety disorders
Metacognitive treatment. Evidence, such as presented by Dobson,¹⁸ suggests that the field of CBT is shifting towards a meta­cognitive model of change and treatment. A metacognitive approach goes beyond changing thinking and emphasizes thoughts about thoughts and experiences. Examples include mindfulness-based cognitive ther­apy (MBCT) and acceptance and commit­ment therapy (ACT).

MBCT typically consists of an 8-week program of 2-hour sessions each week and 1 full-day retreat. MBCT is modeled after Kabat-Zinn’s widely disseminated and empirically supported mindfulness based stress reduction course.¹⁹ MBCT was devel­oped as a relapse prevention program for patients who had recovered from depres­sion. Unlike traditional cognitive therapy for depression that targets changing the content of automatic thoughts and core beliefs, in MBCT patients are aware of negative auto­matic thoughts and find ways to change their relationship with these thoughts, learn­ing that thoughts are not facts. This process mainly is carried out by practicing mind­fulness meditation exercises. Importantly, MBCT goes beyond mindful acceptance of negative thoughts and teaches patients mind­ful acceptance of all internal experiences.

A fundamental difference between ACT and traditional CBT is the approach to cognitions.²⁰ Although CBT focuses on changing the content of maladaptive thoughts, such as “I am a worthless per­son,” ACT focuses on changing the function of thoughts. ACT strives to help patients to accept their internal experiences—whether unwanted thoughts, feelings, bodily sen­sations, or memories—while committing themselves to pursuing their life goals and values. Strategies aim to help patients step back from their thoughts and observe them as just thoughts. The patient who thinks, “I am worthless” would be instructed to prac­tice saying “I am having the thought I am worthless.” Therefore the thought no longer controls the person’s behavior.

These approaches train the patient to keenly observe distressing thoughts and experiences—not necessarily with the goal of changing them but to accept them and act in a way that is consistent with his (her) goals and values. A meta-analysis of 39 stud­ies found mindfulness-based therapy effec­tive in improving symptoms in participants with anxiety and mood disorders.²¹ Similarly, ACT has demonstrated efficacy with mixed anxiety disorders.²²

Transdiagnostic CBT. Recent research18 sug­gests that mood and anxiety disorders may have more commonalities than differences in underlying biological and psychological traits. Because the symptoms of anxiety and depressive disorders tend to overlap, and their rate of comorbidity may be as high as 55%,23 so-called transdiagnostic treatments have been developed. Transdiagnostic treat­ments target impairing symptoms that cut across different diagnoses. For example, patients with depression, anxiety, or sub­stance abuse might share a common dif­ficulty with regulating and coping with negative emotions.

In a preliminary comparison trial,²⁴ 46 patients with social anxiety disorder, panic disorder, or GAD were randomly assigned to transdiagnostic CBT (n = 23) or diagnosis-specific CBT (n = 23). Treatments were based on widely used manuals and offered in 2-hour group sessions across 12 weeks. Transdiagnostic CBT was found to be as effective as specific CBT protocols in terms of symptom improvement. Participants attended an average of 8.46 sessions, with similar attendance in each protocol. Fourteen participants (30%) discontin­ued treatment, similar to attrition rates reported in other trials of transdiagnostic and diagnosis-specific CBT.

Transdiagnostic treatments may facilitate the dissemination of empirically supported treatments because therapists would not be required to have training and supervision to competency in delivering multiple manuals for specific anxiety disorders. This could be attractive to busy practitioners with limited time to learn new treatments.
 

Bottom Line
Efficacy of cognitive-behavioral therapy (CBT) for depression and anxiety is well established. Although no specific technique defines CBT, a common practice is to educate an individual about interrelationships between behaviors/activities, thoughts, and mood. CBT techniques can be customized to treat specific anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalized anxiety disorder.

Disclosures
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.