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Reviews of Note

A proposal on immunosuppressive therapy for schizophrenia patients, an essay clarifying the types of interplay between genes and the environment, an article examining possible taxonomies for DSM-V, and systematic reviews of treatments for post-traumatic stress disorder and back pain.

In an occasional column, Journal Watch Psychiatry editors briefly comment on review articles. These annotations were written by Barbara Geller, MD, Peter Roy-Byrne, MD, and Joel Yager, MD.

Immunosuppression and schizophrenia. These authors argue for a trial of immunosuppressive therapy for patients with schizophrenia, reasoning that many familial aspects, the course of disease, and some biological markers in schizophrenia are similar to those in many established autoimmune diseases.¹ Their rationales include that schizophrenia patients, compared with healthy populations, have a high prevalence of some autoimmune diseases and that a very early trial of low-dose steroid therapy was successful (albeit replications at higher doses were not). Eventually, we will likely find that schizophrenia, like many medical phenotypes, is heterogeneous in its pathogenesis — an etiopathogenesis based in autoimmunity is not improbable in some cases.

How do genes and the environment affect one another? In "gene-environment correlations," genes affect an individual’s behaviors and temperament, which control exposure to the environment. In "gene-environment interactions," genes determine an individual’s sensitivity or vulnerability to an environmental effect. This scholarly review provides numerous examples from cutting-edge behavioral and molecular genetic studies that elucidate the difference between these types of interplay.² The review helps the reader appreciate how gene-environment correlations are an often unappreciated source of confounding that can produce apparent, but false, gene-environment interactions, and how the psychiatric-research literature at this point has not taken full advantage of analytic or design approaches to minimize these confounds. This review is well worth the time for clinicians fond of using "stress-vulnerability" metaphors and concepts in their clinical work — it allows us to appreciate how complex and multidimensional such concepts really are.

What’s in a name? As the psychiatric profession turns to constructing and assembling the DSM-V, controversies about schemes for conceptualizing diagnoses are developing with increasing frequency. These authors thoughtfully introduce six dimensions to be considered for diagnostic categories: causalism–descriptivism, essentialism–nominalism, objectivism–evaluativism, internalism–externalism, entities–agents, and categories–continua.³ The authors also discuss four medical models used in diagnosis (e.g., organic-disease and biopsychosocial models) and map the dimensions onto these models. They also describe two alternative models: an interpersonal systems model and a narrative approach. The authors consider empirical and non-empirical aspects of categorization and make the case that non-empirical values and judgments are inevitably part of a diagnostic system. The issue is how to address them explicitly, judiciously, and wisely.

PTSD treatments: A systematic review. Using meta-analytic techniques where possible, these authors have summarized and compared results from 38 randomized controlled trials of various psychological treatments for adults with post-traumatic stress disorder symptoms that had lasted at least 3 months.⁴ Trauma-focused cognitive-behavioral therapy, eye-movement desensitization and reprocessing (EMDR), stress management, and group CBT have all improved PTSD symptoms more than wait-lists or usual care. The first two listed techniques appear to be the most effective, although the much larger number of studies in these comparisons may have contributed to this impression. Readers may find it useful to peruse the tables to see the results of the various treatment comparisons. The focus on patients who still have PTSD after 3 months makes the article relevant to the clinical practitioner who usually sees people with chronic PTSD.

Opioids for chronic back pain? In a systematic review and meta-analysis of 38 studies, researchers examine the prevalence, benefits, and adverse effects of opioid-medication use for chronic low-back pain.⁵ These drugs are very commonly prescribed and for extensive durations, especially in specialty care centers and for patients with impaired function. However, their efficacy for reducing pain is minimal and documented only for the short term (<16 weeks). Patients treated with opioids have a surprisingly high rate of both lifetime (as high as 54%) and current (as high as 43%) substance-use disorders. The authors suggest that clinicians reconsider use of these medications and look for alternative approaches.

Published in Journal Watch Psychiatry June 18, 2007

Citation(s):

1. Knight JG et al. Rationale for a trial of immunosuppressive therapy in acute schizophrenia. Mol Psychiatry 2007 May; 12:424-31.

• Medline abstract (Free)

2. Jaffee SR and Price TS. Gene-environment correlations: A review of the evidence and implications for prevention of mental illness. Mol Psychiatry 2007 May; 12:432-42.

• Medline abstract (Free)

3. Zachar P and Kendler KS. Psychiatric disorders: A conceptual taxonomy. Am J Psychiatry 2007 Apr; 164:557-65.

• Original article (Subscription may be required)
• Medline abstract (Free)

4. Bisson JI et al. Psychological treatments for chronic post-traumatic stress disorder: Systematic review and meta-analysis. Br J Psychiatry 2007 Feb; 190:97-104.

• Original article (Subscription may be required)
• Medline abstract (Free)

5. Martell BA et al. Systematic review: Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med 2007 Jan 16; 146:116-27.

• Original article (Subscription may be required)
• Medline abstract (Free)