Whole genome sequencing in psychiatric disorders: the WGSPD consortium

As technology advances, whole genome sequencing (WGS) is likely to supersede other genotyping technologies. The rate of this change depends on its relative cost and utility. Variants identified uniquely through WGS may reveal novel biological pathways underlying complex disorders and provide high-resolution insight into when, where, and in which cell type these pathways are affected. Alternatively, cheaper and less computationally intensive approaches may yield equivalent insights. Understanding the role of rare variants in the noncoding gene-regulating genome, through pilot WGS projects, will be critical to determine which of these two extremes best represents reality. With large cohorts, well-defined risk loci, and a compelling need to understand the underlying biology, psychiatric disorders have a role to play in this preliminary WGS assessment. The WGSPD consortium will integrate data for 18,000 individuals with psychiatric disorders, beginning with autism spectrum disorder, schizophrenia, bipolar disorder, and major depressive disorder, along with over 150,000 controls.

Psychotherapy in psychiatry

The relationship between psychotherapy and psychiatry has become a beleagured one in recent years. The swing of the pendulum in the direction of biological psychiatry has led to a marginalization of psychotherapy within the discipline of psychiatry as a whole. However, psychotherapy continues to be a basic science of psychiatry with application in all clinical settings. It must be regarded as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of overall treatment planning. The combined treatment of medication and psychotherapy has become the most common mode of psychiatric treatment planning in current practice. Both the two-treater model and the single-treater model have a set of advantages and disadvantages that are explicated. Further research is needed to identify clinical situations in which psychotherapy is essential, whether alone or in combination with medication. Moreover, as greater insights are gained into the brain mechanisms responsible for therapeutic changes, more specifically targeted psychotherapies can be developed.

How Endangered is Dynamic Psychiatry in Residency Training?

The future of psychodynamic psychotherapy in residency training is in jeopardy. New priorities and forces currently aligned in academic psychiatry challenge the importance of psychodynamic psychotherapy and, by extension, its core concepts of the unconscious, defense and resistance, transference and countertransference, and the past repeating itself in the present. The exit of psychoanalysts from academic centers in the last quarter of the past century was propelled by forces including biological psychiatry, managed care, and competition from other mental health disciplines. ACGME psychotherapy competencies introduced in 2001 renewed the focus on psychotherapy training in residency and set a residency training standard for psychotherapy competency. A recent shift in academia prioritizing evidence-based medicine and a shortage of psychiatrist researchers may threaten those gains.

International Congress of Biological Psychiatry. 8-13 February 2004, Sydney, Australia

Approximately 1500 psychiatrists, psychologists and basic scientists attended the International Congress of Biological Psychiatry with a specialist interest in the biological aspects of psychiatry. There was relatively little information on new medications for the treatment of psychiatric disorders but the congress emphasized approaches to treatment based on medications and physical therapies, as well as advances in the understanding of the biological basis of psychiatric illnesses. Around 800 abstracts were presented in symposia, sponsored satellite sessions, free communications and poster sessions. The poster sessions were particularly well attended and provided many lively discussions. Of particular interest were sessions devoted to new antipsychotics for the treatment of schizophrenia, management of mood and anxiety disorder, Alzheimer's disease and bipolar disorder. This report describes information on the new antipsychotic drug aripiprazole, novel targets for the treatment of mood disorders and psychoses, GABAA receptors in the treatment of panic disorder, and poster presentations on bipolar disorder.

Genetics of personality: are we making progress?

For centuries, scientists are intrigued by the differences in personality between individuals. As early as in the ancient Greek civilization, people tried to formulate theories to systematize this diversity. With the increased interest in behavior genetics, personality was also considered a challenging phenotype. From the early start, studies suggested a heritable component in personality. After the successes of molecular genetic studies in unraveling the genetic basis of (mostly) monogenic diseases, the focus shifted towards complex traits, including psychiatric disorders. It was observed in several studies that personality measures differed between patients with psychiatric disorders and healthy controls. Therefore, normal personality was considered a viable endophenotype in the search for genes involved in psychiatric disorders such as affective disorders, ADHD and substance dependence. Genes that were to be found in studies on personality could be candidate genes for particular psychiatric disorders. In the course of time, however the study of genes for personality turned out to be at least as hard as the search for genes involved in other complex disorders. In this review, past studies, present problems and future directions concerning the study of personality genetics are discussed.

Finding a home for post-traumatic stress disorder in biological psychiatry. Is it a disorder of anxiety, mood, stress, or memory?

The collection of articles in this issue constitutes the most thorough review of posttraumatic stress disorder (PTSD) yet. At this point, the accumulated phenomenological, epidemiological, biological, and treatment evidence make it crystal clear that PTSD stands alone as a unique psychiatric disorder. It is not the same as depression, although many PTSD patients are also depressed, and it is not the same as the other anxiety disorders, although PTSD patients frequently also suffer with panic attacks, social avoidance, and obsessive ruminations.

What can psychiatric genetics offer suicidology?

There is good evidence from recent studies that depression is familial, and that a substantial proportion of the variation in liability is explained by genes. Suicidal behavior, including completed suicide, also seems to cluster in families. First-degree relatives of individuals who have committed suicide (included dizygotic twins) have more than twice the risk of the general population. For identical co-twins of suicides, the relative risk increases to about 11. Applying a simple structural equation model to the published data suggests a heritability for completed suicide of about 43% (95% confidence intervals 25-60). It is not known at present whether the genes predisposing to suicide are identical with those predisposing to affective disorder, but since only about half of those committing suicide have a diagnosis of depression, it seems probable that the overlap is incomplete. The mode of inheritance of suicidal behavior is almost certain to be complex, involving many genes. There have already been some initial studies of allelic association with polymorphisms in candidate genes such as those involved in serotonergic transmission. Further progress is likely to come from candidate gene and linkage disequilibrium studies that are capable of detecting multiple genes of small effect.

[Psychiatry as a profession]

With reference to Max Weber's timeless analysis of science and politics as a profession, the present paper describes the philosophical background and historical development of the tasks and tools, institutionalization, and socialization of psychiatry as a profession. In the mid twentieth century, psychiatrists' emergence from ideological confinement in asylums, where they were separated from urban culture and medicine in general, finally allowed them to benefit from accumulating knowledge and technological progress in the field of medicine. After its transition from a custodial to a therapeutic discipline, psychiatry has acquired a variety of new fields of action and duties that require a high degree of expertise on psychological and biological levels. At the same time, people have increasingly come to expect relief not only from disease, but also from manifold problems of everyday life. As a consequence, there has been an inflationary growth of professional psychiatric and psychotherapeutic and nonprofessional services. The professional requirements that psychiatrists should meet have also increased quantitatively and qualitatively in the wake of the historical change from a caring, paternalistic attitude towards the mentally ill to a therapeutic partnership. To a greater degree than physicians working in other medical fields, psychiatrists get personally involved with their patients. As a consequence, the mental burden of their profession is at times immense. For this reason, the ethics of a medical profession has special implications for psychiatrists. The fascinating advances in therapeutic methods, neurobiological knowledge, and the increasingly differentiated diagnostic tools, e.g., noninvasive investigation of the morphology and functioning of the brain, have turned psychiatry into one of the most interesting contemporary professions. Psychiatry is now facing an enormous challenge of meeting the standards of expertise.

The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist?

OBJECTIVE

The authors suggest that pharmacotherapy and psychotherapy, the major treatment modalities in psychiatry, have become fragmented from one another, creating an artificial separation of the psychosocial and biological domains in psychiatry.

METHOD

After a brief discussion of the economic factors influencing this trend, the authors provide a selective overview of recent research. In the absence of systematic empirical data regarding which patients and which conditions might benefit from integrated treatment by one psychiatrist, the authors propose specific clinical situations that call for such integration and also discuss concerns about cost-effectiveness.

RESULTS

Recent research suggests that combining psychotherapy and pharmacotherapy may have advantages over either treatment alone in certain clinical situations involving specific disorders. While few of the studies on combined treatment have tested whether a one-person or two-person model of treatment provision is more effective, there are a number of advantages to the one-person treatment model in which a psychiatrist conducts the psychotherapy and prescribes medication for the same patient.

CONCLUSIONS

The authors suggest that further research is needed to clarify the optimal situations for the one-person model of integrated treatment and also propose systematic teaching of integrated treatment in all residency training programs.

Psychiatric genetics: recent advances and clinical implications

OBJECTIVE

To present an overview on current progress and future directions in psychiatric genetics.

METHODS

The review of studies that have demonstrated a genetic contribution to a wide range of psychopathology using family, twin, adoption studies and exploration of the methods and limitations of molecular genetic studies.

RESULTS

Single gene disorders has been the area that is most straightforward with striking advances in disorders such as Huntington Disease and early onset familial Alzheimer disease. Complex phenotypes such as schizophrenia and affective disorder have presented greater difficulties but late onset Alzheimer disease and dyslexia are examples where replicated molecular genetic findings suggest that gene identification is feasible even for multifactorial disorders.

CONCLUSION

The combination of increasingly complete information on the genome together with accessibility to this on the internet provide the essential tools for the search for susceptibility genes. Another essential requirement in trying to identify genes of small effect is well characterized large scale collections of cases and this demands the interaction of epidemiological and clinical researchers. Advances in genomics will also allow tailoring of pharmaceuticals pointing at treatment response and side effects. Hopefully all this perspectives together, will improve our understanding of the neurobiological pathogenesis of diseases such as Schizophrenia, Depression and Bipolar disorder 'legitimizing' them in the public view.

Past, present and future of biological psychiatry

These excerpts from the Presidential Address at the 7th World Congress of Biological Psychiatry, Berlin, 2001 attempt to define the term "biological psychiatry", the principle relevance of diagnostic systems for biological psychiatry and the relevance of biological psychiatry in the past and future for the development of psychiatry in general. They also cover the problem of misuse of biological psychiatry and the need for the rigorous observation of ethical standards.

Nature, nurture and mental disorder: old concepts in the new millennium

BACKGROUND

Evidence from twin and adoption studies has highlighted the importance of gene-environment interaction in the aetiology of mental disorders, and advances in molecular genetics have raised hopes of more rapid progress in this field of investigation.

AIMS

To review epidemiological knowledge concerning genetic and environmental risk factors for a cross-section of psychiatric conditions, and evidence of interaction between the two types.

METHOD

Searches of the literature in genetic and psychiatric epidemiology, including contributions to this supplement.

RESULTS

Overall, firm knowledge on both genetic and environmental causal factors is still fragmentary, although progress has varied among diagnostic categories. Environmental aspects have been dealt with only perfunctorily in most genetic epidemiological research.

CONCLUSIONS

Better definition and classification of environmental hazards, and closer inter-disciplinary cooperation, will be necessary in future. Specific gene-environment interaction effects seem likely to prove most important in neuropsychiatric syndromes, and a less specific genetic influence on susceptibility to environmental stress among the common mental disorders.

The promise of psychiatric enviromics

BACKGROUND

The human genome dwells within environment, determines environment and its expression is shaped by environment.

AIMS

To introduce 'psychiatric enviromics' as a complement to human genomics and proteomics as applied to mental health.

METHOD

Selective literature review and synthesis.

RESULTS AND CONCLUSIONS

Psychiatric enviromics can be planned to sustain the search for specific environments or environmental processes and conditions that promote mental health and reduce the occurrence of psychiatric disturbances. Subsets of the psychiatric envirome will be discovered to have functional importance precisely because specific environmental conditions or processes will reduce, amplify or otherwise modulate the expression of specific genes or multiple gene interactions at identifiable periods of life-span development. Other salubrious environmental conditions and processes will have functional importance but lack specificity of action with respect to gene expression. An international collaboration in the form of a review of evidence is proposed as a starting point for 'psychiatric enviromics'.

Preserving the "psychosocial" in an era of biological psychiatry

For psychodynamic thinking and understanding to feel relevant to psychiatric residents in current training programs, it must focus on the clinical problems they encounter with patients. It must be presented in everyday language and in a form applicable to their own clinical experience. Abstract theory or "deep" formulation may alienate rather than attract interest.

The millennium of mind, brain, and behavior

Psychiatry enters the new millennium poised to answer many of its central questions. Given the complexity of the human brain and its interactions with our world, these questions are among the most difficult ever addressed by human science. How is the human brain built? How does it change over the life span? What are the precise genetic and environmental risk factors for mental illnesses? What are the pathophysiologic processes that produce the symptoms and disabilities? How do our treatments, including psychotherapy, work? What objective markers can we discover to monitor the progression of the pathogenic processes and the effects of treatment? How will we discover preventive measures and cures that will be effective in diverse populations and settings? Parallel to the pursuit of its public health agenda, psychiatry will grow closer to neuroscience, behavioral science, and neurology. In so doing, those who practice these disciplines will be better positioned to ask meaningful questions about the relationship among mind, brain, and behavior, and to finally overcome the pervasive Cartesianism that continues to incubate stigma and ignorance about mental illness.

Science and the future of psychiatry

If humanity is lucky, the evolution of our knowledge of the living world will result in the elaboration of more perfect scientific eyes to probe the nature of the human brain and to understand the complexities of the human mind. This seems to be the best path to truly helping individuals who are battling psychiatric illnesses and to actually preventing many brain-related disorders. For such accomplishments to take place, the trajectory of our science has to change, to move from its unrelenting reductionism to a serious attempt at integrating knowledge that spans from the structure of the gene to the expression of complex cognition. The tension between the biomedical and the psychotherapeutic approaches in psychiatry needs to be eliminated and transformed into a fully integrated approach that is mindful of the biological, emotional, cognitive, and social complexity of each individual.

Dopamine D4 receptors: significance for molecular psychiatry at the millennium

Extraordinary progress has been made in the molecular, genetic, anatomical, and pharmacological characterization of dopamine D4 receptors in animal and human brain. Clarification of the neurochemical and physiological roles of these cerebral receptors is emerging. Postmortem neuropathological studies have inconsistently linked D4 receptors to psychotic disorders, and genetic studies have failed to sustain conclusive associations between D4 receptors and schizophrenia. However, associations are emerging between D4 receptors and other neuropsychiatric disorders, including attention deficit hyperactivity disorder, mood disorders, and Parkinson's disease, as well as specific personality traits such as novelty-seeking. Selective D4 agonists and antagonists have been developed as useful experimental probes. D4antagonists, so far, have proved ineffective in treatment of schizophrenia, but testing in a broader range of disorders may yield clinically useful drugs. D4 receptors appear to have broad implications for the pathophysiology of neuropsychiatric illnesses and their improved treatment.

Psychiatric research in the 21st century: opportunities and limitations

The year 2000 prompts numerous prognostications of the events to occur during the next century. Except for the Y2K problem, the year 2000 is little different in substance than 1999 or 2001. However it is useful to use the occasion to consider where we have come from and where we are going. Thinking of the future will help clarify goals, define the problems, identify priorities, and outline pathways for progress.

Mouse models of madness

Psychiatric disorders have important genetic contributions, but it has been very difficult to identify the responsible genes using human populations. Recent developments in mouse genomics hold considerable promise of providing important insights into the genetics of these diseases.