Showing papers in "American Journal of Psychiatry in 2013"
TL;DR: The work group recommendations for DSM-5 revisions included combining abuse and dependence criteria into a single substance use disorder based on consistent findings from over 200,000 study participants, dropping legal problems and adding craving as criteria, and moving gambling disorders to the chapter formerly reserved for substance-related disorders.
Abstract: Since DSM-IV was published in 1994, its approach to substance use disorders has come under scrutiny. Strengths were identified (notably, reliability and validity of dependence), but concerns have also arisen. The DSM-5 Substance-Related Disorders Work Group considered these issues and recommended revisions for DSM-5. General concerns included whether to retain the division into two main disorders (dependence and abuse), whether substance use disorder criteria should be added or removed, and whether an appropriate substance use disorder severity indicator could be identified. Specific issues included possible addition of withdrawal syndromes for several substances, alignment of nicotine criteria with those for other substances, addition of biomarkers, and inclusion of nonsubstance, behavioral addictions.This article presents the major issues and evidence considered by the work group, which included literature reviews and extensive new data analyses. The work group recommendations for DSM-5 revisions includ...
1,039 citations
TL;DR: Ketamine demonstrated rapid antidepressant effects in an optimized study design, further supporting NMDA receptor modulation as a novel mechanism for accelerated improvement in severe and chronic forms of depression.
Abstract: Intravenous ketamine demonstrated rapid antidepressant effects in an optimized study design, improving depression severity in 64% of treatment-resistant patients 24 hours after a single dose. The double-blind trial provides evidence for the role of the N-methyl-d-aspartate glutamate receptor in depression, a receptor not currently activated by existing antidepressant drugs.
943 citations
TL;DR: Better evidence for efficacy from blinded assessments is required for behavioral interventions, neurofeedback, cognitive training, and restricted elimination diets before they can be supported as treatments for core ADHD symptoms.
Abstract: A meta-analytic review of six types of nonpharmacological interventions, including dietary and psychological treatments, for children with ADHD found positive effects on ADHD symptoms for all types when raters were aware of treatment allocation (unblinded conditions). However, when raters were blinded, statistically significant effects on ADHD symptoms were found only for supplementation with omega-3/omega-6 free fatty acids or elimination of artificial food colorings, effects that were small or restricted to food-sensitive individuals.
937 citations
TL;DR: Most diagnoses adequately tested had good to very good reliability with these representative clinical populations assessed with usual clinical interview methods.
Abstract: ObjectiveThe DSM-5 Field Trials were designed to obtain precise (standard error <0.1) estimates of the intraclass kappa as a measure of the degree to which two clinicians could independently agree on the presence or absence of selected DSM-5 diagnoses when the same patient was interviewed on separate occasions, in clinical settings, and evaluated with usual clinical interview methods.MethodEleven academic centers in the United States and Canada were selected, and each was assigned several target diagnoses frequently treated in that setting. Consecutive patients visiting a site during the study were screened and stratified on the basis of DSM-IV diagnoses or symptomatic presentations. Patients were randomly assigned to two clinicians for a diagnostic interview; clinicians were blind to any previous diagnosis. All data were entered directly via an Internet-based software system to a secure central server. Detailed research design and statistical methods are presented in an accompanying article.ResultsThere ...
786 citations
TL;DR: Phenotypic expression of psychopathology may be strongly influenced by exposure to maltreatment, leading to a constellation of ecophenotypes that fit within conventional diagnostic boundaries, but likely represent distinct subtypes.
Abstract: ObjectiveChildhood maltreatment increases risk for psychopathology. For some highly prevalent disorders (major depression, substance abuse, anxiety disorders, and posttraumatic stress disorder) a substantial subset of individuals have a history of maltreatment and a substantial subset do not. The authors examined the evidence to assess whether those with a history of maltreatment represent a clinically and biologically distinct subtype.MethodThe authors reviewed the literature on maltreatment as a risk factor for these disorders and on the clinical differences between individuals with and without a history of maltreatment who share the same diagnoses. Neurobiological findings in maltreated individuals were reviewed and compared with findings reported for these disorders.ResultsMaltreated individuals with depressive, anxiety, and substance use disorders have an earlier age at onset, greater symptom severity, more comorbidity, a greater risk for suicide, and poorer treatment response than nonmaltreated indi...
766 citations
TL;DR: The CAINS is an empirically developed and evaluated measure of negative symptoms that is brief yet comprehensive and employable across a wide range of research and clinical contexts.
Abstract: ObjectiveA major barrier to developing treatments for negative symptoms has been measurement concerns with existing assessment tools. Fulfilling the top recommendation of the National Institute of Mental Health’s Consensus Development Conference on Negative Symptoms, the Clinical Assessment Interview for Negative Symptoms (CAINS) was developed using an iterative, empirical approach, and includes items assessing motivation, pleasure, and emotion expression. The authors employed multiple analytic techniques to develop the CAINS and here provide final development and validation results.MethodThe CAINS structure, interrater agreement, test-retest reliability, and convergent and discriminant validity were assessed in a large and diverse sample of 162 outpatients with schizophrenia or schizoaffective disorder recruited from four sites.ResultsThree items with poor psychometric properties were removed, resulting in a 13-item CAINS. The CAINS factor structure was replicated, demonstrating two modestly correlated s...
551 citations
TL;DR: Schizophrenia patients had markedly premature mortality, and the leading causes were ischemic heart disease and cancer, which appeared to be underdiagnosed.
Abstract: ObjectiveSchizophrenia is associated with premature mortality, but the specific causes and pathways are unclear. The authors used outpatient and inpatient data for a national population to examine the association between schizophrenia and mortality and comorbidities.MethodThis was a national cohort study of 6,097,834 Swedish adults, including 8,277 with schizophrenia, followed for 7 years (2003–2009) for mortality and comorbidities diagnosed in any outpatient or inpatient setting nationwide.ResultsOn average, men with schizophrenia died 15 years earlier, and women 12 years earlier, than the rest of the population, and this was not accounted for by unnatural deaths. The leading causes were ischemic heart disease and cancer. Despite having twice as many health care system contacts, schizophrenia patients had no increased risk of nonfatal ischemic heart disease or cancer diagnoses, but they had an elevated mortality from ischemic heart disease (adjusted hazard ratio for women, 3.33 [95% CI=2.73–4.05]; for me...
511 citations
TL;DR: A consensus was reached on 12 statements on the use of antidepressants in bipolar disorder, and antidepressants should be prescribed only as an adjunct to mood-stabilizing medications.
Abstract: A task force report presents 12 recommendations for antidepressant use in bipolar disorder rated by at least 80% of International Society for Bipolar Disorders experts as essential or important.
475 citations
TL;DR: Overall, the literature suggests that disturbed REM or non-REM sleep can contribute to maladaptive stress and trauma responses and may constitute a modifiable risk factor for poor psychiatric outcomes.
Abstract: The hypothesis that rapid eye movement (REM) sleep disturbances are the hallmark of posttraumatic stress disorder (PTSD), proposed by Ross and colleagues in 1989, has stimulated a wealth of clinical, preclinical, and animal studies on the role of sleep in the pathophysiology of PTSD. The present review revisits this influential hypothesis in light of clinical and experimental findings that have since accumulated. Polysomnographic studies conducted in adults with PTSD have yielded mixed findings regarding REM sleep disturbances, and they generally suggest modest and nonspecific sleep disruptions. Prospective and treatment studies have provided more robust evidence for the relationship between sleep disturbances and psychiatric outcomes and symptoms. Experimental animal and human studies that have probed the relationship between REM sleep and fear responses, as well as studies focused more broadly on sleep-dependent affective and memory processes, also provide strong support for the hypothesis that sleep pl...
456 citations
TL;DR: Increasing resilience and reducing depression might have effects on successful aging as strong as that of reducing physical disability, suggesting an important role for psychiatry in promoting successful aging.
Abstract: In a survey of 1,006 community-dwelling adults ages 50 to 99, self-rated “successful aging” was surprisingly more common in the oldest respondents. Greater age was associated with worse physical and cognitive functioning but also with higher levels of optimism and resilience and less depression. People with the poorest physical functioning who had high degrees of resilience had self-ratings of successful aging similar to those of physically healthy people with low resilience.
371 citations
TL;DR: The findings strongly support the claim that patients with bipolar disorder are at high risk for metabolic syndrome and related cardiovascular morbidity and mortality and require regular monitoring and adequate preventive efforts and treatment for cardio-metabolic risk factors.
Abstract: ObjectivePatients with bipolar disorder have high levels of cardiovascular disease risk factors. The presence of metabolic syndrome significantly influences future cardiovascular disease morbidity and mortality. The authors sought to clarify the prevalence and moderators of metabolic syndrome in bipolar patients, accounting for subgroup differences.MethodThe authors searched MEDLINE, PsycINFO, EMBASE, and CINAHL through April 2012 for research reporting metabolic syndrome prevalence rates in bipolar patients. Medical subject headings “metabolic syndrome” and “bipolar” were used in the title, abstract, or index term fields. Manual searches were conducted using the reference lists from identified articles.ResultsThe search yielded 81 articles in 37 publications (N=6,983). The overall metabolic syndrome rate was 37.3% (95% confidence interval [CI]=36.1–39.0) using any standardized metabolic syndrome criteria. Compared with general population groups, bipolar patients had higher metabolic syndrome rates (odds ...
TL;DR: The authors found that exposure to childhood trauma predicted newly incident psychotic experiences, and provides the first direct evidence that cessation of traumatic experiences leads to a reduced incidence of psychotic experiences.
Abstract: Exposure to physical abuse and bullying during childhood was strongly predictive of psychotic experiences in individuals who had never before had symptoms, and stopping the trauma led to a significant drop in the frequency of psychotic experiences. The study adds weight to calls for effective interventions to curtail bullying at school and abuse at home to reduce psychotic experiences in the population.
TL;DR: These results show promising test-retest reliability results for this group of assessments, many of which are newly developed or have not been previously tested in psychiatric populations.
Abstract: ObjectiveThe authors sought to document, in adult and pediatric patient populations, the development, descriptive statistics, and test-retest reliability of cross-cutting symptom measures proposed for inclusion in DSM-5.MethodData were collected as part of the multisite DSM-5 Field Trials in large academic settings. There were seven sites focusing on adult patients and four sites focusing on child and adolescent patients. Cross-cutting symptom measures were self-completed by the patient or an informant before the test and the retest interviews, which were conducted from 4 hours to 2 weeks apart. Clinician-report measures were completed during or after the clinical diagnostic interviews. Informants included adult patients, child patients age 11 and older, parents of all child patients age 6 and older, and legal guardians for adult patients unable to self-complete the measures. Study patients were sampled in a stratified design, and sampling weights were used in data analyses. The mean scores and standard d...
TL;DR: Robust cognitive deficits are present and familial in schizophrenia and psychotic bipolar disorder and Severity of cognitive impairments across psychotic disorders was consistent with a continuum model, in which more prominent affective features and less enduring psychosis were associated with less cognitive impairment.
Abstract: ObjectiveFamilial neuropsychological deficits are well established in schizophrenia but remain less well characterized in other psychotic disorders. This study from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium 1) compares cognitive impairment in schizophrenia and bipolar disorder with psychosis, 2) tests a continuum model of cognitive dysfunction in psychotic disorders, 3) reports familiality of cognitive impairments across psychotic disorders, and 4) evaluates cognitive impairment among nonpsychotic relatives with and without cluster A personality traits.MethodParticipants included probands with schizophrenia (N=293), psychotic bipolar disorder (N=227), schizoaffective disorder (manic, N=110; depressed, N=55), their first-degree relatives (N=316, N=259, N=133, and N=64, respectively), and healthy comparison subjects (N=295). All participants completed the Brief Assessment of Cognition in Schizophrenia (BACS) neuropsychological battery.ResultsCognitive impairments among...
TL;DR: Disruptive mood dysregulation disorder is relatively uncommon after early childhood, frequently co-occurs with other psychiatric disorders, and meets common standards for psychiatric "caseness."
Abstract: The low prevalence rates in three large community samples of children (0.8% to 3.3%) for the new proposed diagnosis of disruptive mood dysregulation disorder suggest that the diagnosis will not be extensively applied to children with normal behavior. Although the core symptoms are common, the criteria regarding frequency, duration, and context exclude most children. The diagnosis is associated with high levels of social impairment, school suspension, service use, and poverty. It frequently co-occurs with other psychiatric conditions, especially oppositional defiant disorder and depressive disorders, but overlapped only partially with severe mood dysregulation, the research diagnosis on which it was based.
TL;DR: Prazosin was effective for trauma nightmares, sleep quality, global function, CAPS score, and the CAPS hyperarousal symptom cluster in active-duty soldiers, and benefits are clinically meaningful.
Abstract: ObjectiveThe authors conducted a 15-week randomized controlled trial of the alpha-1 adrenoreceptor antagonist prazosin for combat trauma nightmares, sleep quality, global function, and overall symptoms in active-duty soldiers with posttraumatic stress disorder (PTSD) returned from combat deployments to Iraq and Afghanistan.MethodSixty-seven soldiers were randomly assigned to treatment with prazosin or placebo for 15 weeks. Drug was titrated based on nightmare response over 6 weeks to a possible maximum dose of 5 mg midmorning and 20 mg at bedtime for men and 2 mg midmorning and 10 mg at bedtime for women. Mean achieved bedtime doses were 15.6 mg of prazosin (SD=6.0) and 18.8 mg of placebo (SD=3.3) for men and 7.0 mg of prazosin (SD=3.5) and 10.0 mg of placebo (SD=0.0) for women. Mean achieved midmorning doses were 4.0 mg of prazosin (SD=1.4) and 4.8 mg of placebo (SD=0.8) for men and 1.7 mg of prazosin (SD=0.5) and 2.0 mg of placebo (SD=0.0) mg for women. Primary outcome measures were the nightmare item o...
TL;DR: Symptoms, psychosocial functioning, and familial lineage overlap across the three DSM-IV psychosis diagnoses used in B-SNIP provide scant evidence for distinct phenotypic clustering around traditional phenomenological diagnoses.
Abstract: ObjectiveDeveloping categorical diagnoses that have biological meaning within the clinical phenotype of psychosis (schizophrenia, schizoaffective disorder, and bipolar I disorder with psychosis) is as important for developing targeted treatments as for nosological goals. The Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) was formed to examine a broad array of intermediate phenotypes across psychotic disorders and to test the hypothesis that intermediate phenotype characteristics are homogeneous within phenomenologically derived DSM-IV diagnoses.MethodThe consortium recruited 933 stable probands with schizophrenia, schizoaffective disorder, or psychotic bipolar I disorder, 1,055 of their first-degree relatives, and 459 healthy comparison subjects for clinical characterization and dense phenotyping. Clinical, psychosocial, and family characteristics were contrasted.ResultsAll proband groups showed lower psychosocial functioning than the relatives or comparison group. On average, schizophr...
TL;DR: Extended periods of relapse may have a negative effect on brain integrity in schizophrenia, suggesting the importance of implementing proactive measures that may prevent relapse and improve treatment adherence.
Abstract: ObjectiveLongitudinal structural MRI studies have shown that patients with schizophrenia have progressive brain tissue loss after onset. Recurrent relapses are believed to play a role in this loss, but the relationship between relapse and structural MRI measures has not been rigorously assessed. The authors analyzed longitudinal data to examine this question.MethodsThe authors studied data from 202 patients drawn from the Iowa Longitudinal Study of first-episode schizophrenia for whom adequate structural MRI data were available (N=659 scans) from scans obtained at regular intervals over an average of 7 years. Because clinical follow-up data were obtained at 6-month intervals, the authors were able to compute measures of relapse number and duration and relate them to structural MRI measures. Because higher treatment intensity has been associated with smaller brain tissue volumes, the authors also examined this countereffect in terms of dose-years.ResultsRelapse duration was related to significant decreases...
TL;DR: Despite evidence for a continuum of psychotic experiences from as early as age 12, positive predictive values for predicting psychotic disorders were too low to offer real potential for targeted interventions.
Abstract: OBJECTIVE The authors examined the development of psychotic experiences and psychotic disorders in a large population-based sample of young adults and explored their relationship to psychotic phenomena earlier in childhood. METHOD The authors conducted a longitudinal birth cohort study of individuals assessed with the semistructured Psychosis-Like Symptom Interviews at ages 12 and 18 years. RESULTS Of the 4,724 individuals interviewed at age 18, 433 (9.2%) had either suspected (N=203 [4.3%]) or definite (N=230 [4.9%]) psychotic experiences. Of these, 79 (1.7%) met criteria for a psychotic disorder, and of those, only 50% sought professional help. All psychotic outcomes were more likely in young women and in those from socioeconomically disadvantaged backgrounds. Of the participants who had psychotic experiences at age 12, 78.7% had remitted by age 18. The risk of psychotic disorders at age 18 was greater in those with suspected (odds ratio=5.6, 95% CI=2.6-12.1) and especially in those with definite (odds ratio=12.7, 95% CI=6.2-26.1) psychotic experiences at age 12, and also among those with psychotic experiences at age 12 attributed to sleep or fever or with nonpsychotic experiences such as depersonalization. The positive predictive values for increasing frequency of experiences at age 12 predicting psychotic disorders at age 18 ranged from 5.5% to 22.8%. CONCLUSIONS Despite evidence for a continuum of psychotic experiences from as early as age 12, positive predictive values for predicting psychotic disorders were too low to offer real potential for targeted interventions. Psychotic disorders in young adults are relatively uncommon, but they constitute an important unmet need for care given that half of the individuals in this study who met criteria for a psychiatric disorder had not sought help for these problems despite high levels of associated distress and impairment.
TL;DR: It is suggested that a long duration of illness, substance abuse, low weight, and poor psychosocial functioning raise the risk for mortality in anorexia nervosa.
Abstract: ObjectiveAlthough anorexia nervosa has a high mortality rate, our understanding of the timing and predictors of mortality in eating disorders is limited. The authors investigated mortality in a long-term study of patients with eating disorders.MethodBeginning in 1987, 246 treatment-seeking female patients with anorexia nervosa or bulimia nervosa were interviewed every 6 months for a median of 9.5 years to obtain weekly ratings of eating disorder symptoms, comorbidity, treatment participation, and psychosocial functioning. From January 2007 to December 2010 (median follow-up of 20 years), vital status was ascertained with a National Death Index search.ResultsSixteen deaths (6.5%) were recorded (lifetime anorexia nervosa, N=14; bulimia nervosa with no history of anorexia nervosa, N=2). The standardized mortality ratio was 4.37 (95% CI=2.4–7.3) for lifetime anorexia nervosa and 2.33 (95% CI=0.3–8.4) for bulimia nervosa with no history of anorexia nervosa. Risk of premature death among patients with lifetime ...
TL;DR: Functional remediation showed efficacy in improving the functional outcome of a sample of euthymic bipolar patients as compared with treatment as usual, suggesting an interaction between treatment assignment and time.
Abstract: This novel neurocognitive intervention significantly improved occupational and interpersonal functioning in patients with bipolar I and II disorder
TL;DR: CBT and psychodynamic therapy were both efficacious in treating social anxiety disorder, but there were significant differences in favor of CBT.
Abstract: ObjectiveVarious approaches to cognitive-behavioral therapy (CBT) have been shown to be effective for social anxiety disorder. For psychodynamic therapy, evidence for efficacy in this disorder is scant. The authors tested the efficacy of psychodynamic therapy and CBT in social anxiety disorder in a multicenter randomized controlled trial.MethodIn an outpatient setting, 495 patients with social anxiety disorder were randomly assigned to manual-guided CBT (N=209), manual-guided psychodynamic therapy (N=207), or a waiting list condition (N=79). Assessments were made at baseline and at end of treatment. Primary outcome measures were rates of remission and response, based on the Liebowitz Social Anxiety Scale applied by raters blind to group assignment. Several secondary measures were assessed as well.ResultsRemission rates in the CBT, psychodynamic therapy, and waiting list groups were 36%, 26%, and 9%, respectively. Response rates were 60%, 52%, and 15%, respectively. CBT and psychodynamic therapy were signi...
TL;DR: Visual orienting latencies were longer in 7-month-old infants who expressed ASD symptoms at 25 months compared with both high-risk negative infants and low-risk infants, and abnormal functional specialization of posterior cortical circuits directly informs a novel model of ASD pathogenesis.
Abstract: Specific differences in visual orienting, critical in social-cognitive development, are associated with differences in white matter microstructure of the splenium.
TL;DR: Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice- based collaborative care with locally available staff, according to this multisite randomized pragmatic comparative effectiveness trial.
Abstract: Using telemedicine technologies, off-site mental health specialists collaborating with on-site primary care physicians yielded better depression outcomes than practice-based care with staff available on-site. In this study of mostly rural, unemployed, and uninsured patients with treatment-resistant depression and numerous comorbidities, those patients assigned to a telemedicine-based group had significantly and substantially greater treatment response rates, remission rates, reductions in depression severity, and increases in mental health status and quality of life than patients assigned to the practice-based care group.
TL;DR: This model helps explain the resistance of anorexia nervosa to interventions that have established efficacy in related disorders and implies that addressing the dieting behavior is critical, especially early in the course of the illness, before it has become ingrained.
Abstract: ObjectiveIn this review, based on recent advances in cognitive neuroscience, the author presents a formulation in which the marked persistence of anorexia nervosa can be usefully understood as a well-ingrained maladaptive habit.MethodThe author reviewed the relevant literature on the development and course of anorexia nervosa and interpreted critical features in light of developments in cognitive neuroscience.ResultsAnorexia nervosa is a well characterized disorder with remarkable persistence both across history and among affected individuals. Food restriction, the salient behavioral feature of the disorder, often begins innocently but gradually takes on a life of its own. Over time, it becomes highly entrenched and resistant to change through either psychological or pharmacological treatment. Cognitive neuroscience has described two related but distinct processes that underlie the acquisition of new patterns of behavior, namely, action-outcome and stimulus-response learning. It is likely that both proces...
TL;DR: This issue detail the process and results of reliability tests for proposed DSM-5 diagnoses and cross-diagnosis symptom domains and highlights the good reliability of borderline personality disorder.
Abstract: Three articles in this issue detail the process and results of reliability tests for proposed DSM-5 diagnoses and cross-diagnosis symptom domains The editorial highlights the good reliability of borderline personality disorder and relates the questionable reliability of major depressive disorder to its heterogeneity The editorial is also available in Spanish, Traditional Chinese, and Simplified Chinese
TL;DR: Neural plasticity during development appears to result in cortical adaptation that may shield a child from the sensory processing of the specific abusive experience by altering cortical representation fields in a regionally highly specific manner.
Abstract: ObjectiveSexual dysfunction is a common clinical symptom in women who were victims of childhood sexual abuse. The precise mechanism that mediates this association remains poorly understood. The authors evaluated the relationship between the experience of childhood abuse and neuroplastic thinning of cortical fields, depending on the nature of the abusive experience.MethodThe authors used MRI-based cortical thickness analysis in 51 medically healthy adult women to test whether different forms of childhood abuse were associated with cortical thinning in areas critical to the perception and processing of specific behavior implicated in the type of abuse.ResultsExposure to childhood sexual abuse was specifically associated with pronounced cortical thinning in the genital representation field of the primary somatosensory cortex. In contrast, emotional abuse was associated with cortical thinning in regions relevant to self-awareness and self-evaluation.ConclusionsNeural plasticity during development appears to r...
TL;DR: Despite increased statistical power accorded by meta-analysis, the authors identified no reliable predictors of antidepressant treatment outcome, although they did identify modest, direct evidence that common genetic variation contributes to individual differences in antidepressant response.
Abstract: ObjectiveIndirect evidence suggests that common genetic variation contributes to individual differences in antidepressant efficacy among individuals with major depressive disorder, but previous studies may have been underpowered to detect these effects.MethodA meta-analysis was performed on data from three genome-wide pharmacogenetic studies (the Genome-Based Therapeutic Drugs for Depression [GENDEP] project, the Munich Antidepressant Response Signature [MARS] project, and the Sequenced Treatment Alternatives to Relieve Depression [STAR*D] study), which included 2,256 individuals of Northern European descent with major depressive disorder, and antidepressant treatment outcomes were prospectively collected. After imputation, 1.2 million single-nucleotide polymorphisms were tested, capturing common variation for association with symptomatic improvement and remission after up to 12 weeks of antidepressant treatment.ResultsNo individual association met a genome-wide threshold for statistical significance in t...
TL;DR: The negative effect of chronic maternal depression on child social outcomes was related to genetic and peripheral biomarkers of the oxytocin system, suggesting a potential for oxytocIn-based interventions.
Abstract: Chronic maternal depression negatively affects a child’s social engagement, empathy, and development, but an oxytocin-based intervention may be possible.
TL;DR: Research aimed at reducing placebo response should focus on limiting patient expectancy and the intensity of therapeutic contact in antidepressant clinical trials, while the optimal strategy in clinical practice may be to combine active medication with a presentation and level of therapeutic Contact designed to enhance treatment response.
Abstract: Placebo response in clinical trials of antidepressant medications is substantial and has been increasing. High placebo response rates hamper efforts to detect signals of efficacy for new antidepressant medications, contributing to trial failures and delaying the delivery of new treatments to market. Media reports seize upon increasing placebo response and modest advantages for active drugs as reasons to question the value of antidepressant medication, which may further stigmatize treatments for depression and dissuade patients from accessing mental health care. Conversely, enhancing the factors responsible for placebo response may represent a strategy for improving available treatments for major depressive disorder. A conceptual framework describing the causes of placebo response is needed in order to develop strategies for minimizing placebo response in clinical trials, maximizing placebo response in clinical practice, and talking with depressed patients about the risks and benefits of antidepressant med...