An integrative approach to psychiatric diagnosis and research

Much attention has been paid to revisions of psychiatric classification systems. Nevertheless, there remains significant dissatisfaction with the nosology. From a neuroscience perspective, diagnostic criteria have failed to incorporate neurobiological data, and a focus on “circuit-based behavioral dimensions” (1) will improve diagnosis. From a more critical perspective, given that psychiatric disorders do not represent valid disease entities (1), diagnosis merely medicalizes problems in living. These specific debates echo larger debates about classification in medicine, in which many emphasize notions of disease, arguing that clinicians must 51 be scientists who understand physiology, while others emphasize the experience of illness, stating that clinicians must be humanists who understand suffering (2). An integrative medicine and psychiatry arguably recognizes each of these aspects of being a good diagnostician and researcher (3,4)

The assessment and treatment of panic disorder in general practice

Panic disorder (PD) is an anxiety disorder that affects many South Africans. If undiagnosed or mismanaged, this condition may impact profoundly on an individual's functioning and quality of life. At the primary level, the assessment of panic attacks requires consideration of a number of differential diagnoses. General practitioners also play an invaluable role in the acute and long-term care and appropriate referral of individuals with PD. This article provides an overview of PD in general practice and includes a guideline for case identification and therapeutic options

Buspirone is an effective augmenting agent of serotonin selective re-uptake inhibitors in severe treatment-refractory depression

Background. Buspirone has previously been reported to be effective in the augmentation of the antidepressant effect of serotonin selective re-uptake inhibitors (SSRls) in depressed outpatients. We report on buspirone augmentation of SSRls in severe treatment-refractory depression in inpatients.Methods. A retrospective chart review was undertaken of patients diagnosed with DSM-III-R major depression and treated at our inpatient unit. All 14 patients had been given structured depression rating scales before and after addition of buspirone to a SSRLResults. Patients had previously failed mUltiple trials of antidepressants, often including lithium and/or thyroid augmentation, as well as, in 12 cases, electroconvulsive therapy. However, augmentation of an SSRI with buspirone led to a rapid and significant improvement in depression in 6 of 14 (43%) patients.Conclusion. Despite the limitations of the study design, our resutts support previous work. suggesting the need for further controlled research on the use of buspirone in the augmentation of the antidepressant response to the SSRls

A survey of participants in two internet support groups for people with hair-pulling

The original publication is available at http://www.biomedcentral.com/1471-244X/5/37Background: A substantial number of patients suffering from psychological problems or psychiatric disorders have turned to internet support groups for help. This paper reports on the perceived effectiveness of trichotillomania (TTM) internet support groups for people suffering from hair-pulling. Methods: A questionnaire was sent via e-mail to all subscribers of two mailing lists devoted to TTM, each of which takes a somewhat different approach to the condition. The questionnaire addressed the possible benefits and problems associated with belonging to a TTM virtual support group. Results: Subscribers had similar demographic features as clinical samples of trichotillomania patients. Subscribers to both internet lists found them helpful in terms of feeling supported and in obtaining information. The different approaches to TTM on the two lists were associated with differences in treatments attempted by participants. Conclusion: Internet support groups can potentially contribute to increasing awareness about and knowledge of psychiatric disorders such as TTM, as well as to their management. Nevertheless, additional effort is required to ensure that subscribers are able to make informed, evidence-based decisions

Sexual health in the South African context

Sexual health is a major area of relevance to global public health. The World Health Organization (WHO) has stipulated that every person has the right to sexual health. The United Nations Educational, Scientific and Cultural Organization (UNESCO) has identified sexual rights and sexual health education and training as a global priority. There is also growing interest in human rights and lesbian, gay, bisexual, transgender and intersex (LGBTI) issues internationally. However, there are few centres of excellence for sexual health in low- and middle-income countries, where the vast majority of the world’s population live, and there is a real need to establish such resources.

Sexual dysfunction: A systematic review of South African research

Background. The World Health Organisation is in the process of revising the International Classification of Diseases and Related Health Problems (ICD). Sexual dysfunction disorders (F52) categories have been identified as having poor clinical utility. South Africa (SA) has been selected as one of five low- and middle-income countries in which studies will be developed to assess the clinical utility of the proposed ICD-11 revisions for sexual dysfunctions. Objective. To identify scientific research generated in SA on sexual dysfunction disorders to guide these clinic-based field studies. Methods. A systematic review of SA research on the topic of sexual dysfunctions published in SA peer-reviewed medical journals. Results. Despite the high prevalence of ejaculatory and erectile dysfunctions, only five SA articles have addressed male sexual dysfunction in SA journals since 1970. Lack of sexual interest and inability to reach orgasm are the most commonly reported complaints for women, yet only four SA articles have been published on the topic of female dysfunction. Diabetes mellitus, cardiovascular disease, genitourinary disease and psychiatric or psychological disorders are common comorbid conditions associated with sexual dysfunction across sexes, but only nine articles address sexual dysfunction as the main topic with respect to comorbid conditions. Conclusion. Despite growing awareness of the importance of sexual health, SA-based scientific research on sexual dysfunction is limited. Further work is needed to inform recommendations for ICD-11 revisions drawn from the SA context

Towards a genuinely medical model for psychiatric nosology

Abstract Psychiatric nosology is widely criticized, but solutions are proving elusive. Planned revisions of diagnostic criteria will not resolve heterogeneity, comorbidity, fuzzy boundaries between normal and pathological, and lack of specific biomarkers. Concern about these difficulties reflects a narrow model that assumes most mental disorders should be defined by their etiologies. A more genuinely medical model uses understanding of normal function to categorize pathologies. For instance, understanding the function of a cough guides the search for problems causing it, and decisions about when it is expressed abnormally. Understanding the functions of emotions is a foundation missing from decisions about emotional disorders. The broader medical model used by the rest of medicine also recognizes syndromes defined by failures of functional systems or failures of feedback control. Such medical syndromes are similar to many mental diagnoses in their multiple causes, blurry boundaries, and nonspecific biomarkers. Dissatisfaction with psychiatric nosology may best be alleviated, not by new diagnostic criteria and categories, but by more realistic acknowledgment of the untidy landscape of mental and other medical disorders.http://deepblue.lib.umich.edu/bitstream/2027.42/113195/1/12916_2011_Article_492.pd

Pharmacotherapy for post-traumatic stress disorder : a systematic review and meta-analysis

The original publication is available at http://www.samj.org.zaCITATION: Ipser, J., [et al.]. 2006. Pharmacotherapy for post-traumatic stress disorder: a systematic review and meta-analysis. South African Medical Journal, 96(10):1088-1096.Background. Post-traumatic stress disorder (PTSD) is a prevalent and disabling condition. Evidence that PTSD is characterised by specific psychobiological dysfunctions has contributed to a growing interest in use of medication in its treatment. Objectives. To assess the effects of medication in the treatment of PTSD. Design. Systematic review of randomised controlled trials (RCTs) following the Cochrane Collaboration guidelines. A more detailed version of the review is published in the Cochrane Database of Systematic Reviews. Methods. We searched the Cochrane Depression, Anxiety and Neurosis Group specialised register, the Cochrane Central Register of Controlled Trials (Cochrane Library issue 4, 2004), MEDLINE (January 1966 - December 2004), PsycINFO (1966 - 2004), the National PTSD Center Pilots database, and the meta register module of the Controlled Trials'database. Reference lists of retrieved articles were searched for additional studies. Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by medication class, and by medication agent for the selective serotonin-re-uptake inhibitors (SSRIs). Dichotomous and continuous measures were calculated using a random effects model, heterogeneity was assessed, and subgroup/sensitivity analyses were done. Main results. Thirty-five short-term (14 weeks or less) RCTs were included in the analysis (4 547, participants). Symptom severity for 17 trials was significantly reduced in the medication groups, relative to placebo (weighted mean difference (WMD) = -5.76, 95% confidence interval (CI): -8.16 - -3.36, N = 2 507). Similarly, summary statistics for responder status from 13 trials demonstrated overall superiority of a variety of medication agents compared with placebo (relative risk (RR) = 1.49, 95% CI: 1.28, 1.73, number needed to treat (NNT) = 4.85, N = 1272). Medication and placebo response occurred in 59.1% (N = 644) and 38.5% (N = 628) of patients, respectively. Of the medication classes, evidence of treatment efficacy was most convincing for the SSRIs. Medication was also effective in reducing the severity of the PTSD re-experiencing/intrusion, avoidance/numbing, and hyperarousal symptom clusters in 9 trials (N = 1 304). In addition, medication was superior to placebo in reducing co-morbid depression and disability. Medication was also less well tolerated than placebo. A narrative review of the 3 maintenance trials suggested that long-term medication may be required in treating PTSD. Conclusion. Medication treatments can be effective in treating PTSD, acting to reduce its core symptoms, as well as associated depression and disability, and should be considered as part of the treatment of this disorder. The findings of this review support the status of SSRIs as first-line agents in the pharmacotherapy of PTSD, as well as their value in long-term treatment. However, there remain important gaps in the evidence base, and there is a continued need for more effective agents in the management of PTSD.Publisher’s versio

Guest Editorial

Intellectual disability in South Africa: Addressing a crisis in mental health service