Showing papers in "Annual Review of Clinical Psychology in 2014"
TL;DR: ESEM, an overarching integration of the best aspects of CFA/SEM and traditional EFA, provides confirmatory tests of a priori factor structures, relations between latent factors and multigroup/multioccasion tests of full (mean structure) measurement invariance.
Abstract: Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), path analysis, and structural equation modeling (SEM) have long histories in clinical research. Although CFA has largely superseded EFA, CFAs of multidimensional constructs typically fail to meet standards of good measurement: goodness of fit, measurement invariance, lack of differential item functioning, and well-differentiated factors in support of discriminant validity. Part of the problem is undue reliance on overly restrictive CFAs in which each item loads on only one factor. Exploratory SEM (ESEM), an overarching integration of the best aspects of CFA/SEM and traditional EFA, provides confirmatory tests of a priori factor structures, relations between latent factors and multigroup/multioccasion tests of full (mean structure) measurement invariance. It incorporates all combinations of CFA factors, ESEM factors, covariates, grouping/multiple-indicator multiple-cause (MIMIC) variables, latent growth, and complex structures that typically have required CFA/SEM. ESEM has broad applicability to clinical studies that are not appropriately addressed either by traditional EFA or CFA/SEM.
1,052 citations
TL;DR: A heuristic model is presented postulating that anhedonia arises from dysfunctional interactions between stress and brain reward systems, and a synthesis of these four literatures is provided.
Abstract: Depression is a significant public health problem, but its etiology and pathophysiology remain poorly understood. Such incomplete understanding likely arises from the fact that depression encompasses a heterogeneous set of disorders. To overcome these limitations, renewed interest in intermediate phenotypes (endophenotypes) has resurfaced, and anhedonia has emerged as one of the most promising endophenotypes of depression. Here, a heuristic model is presented postulating that anhedonia arises from dysfunctional interactions between stress and brain reward systems. To this end, we review and integrate three bodies of independent literature investigating the role of (a) anhedonia, (b) dopamine, and (c) stress in depression. In a fourth section, we summarize animal data indicating that stress negatively affects mesocorticolimbic dopaminergic pathways critically implicated in incentive motivation and reinforcement learning. In the last section, we provide a synthesis of these four literatures, present initial evidence consistent with our model, and discuss directions for future research.
786 citations
TL;DR: The most urgent research agenda concerns primary candidates for modifiable risk factors contributing to this excess mortality, i.e., side effects of treatment and lifestyle factors, as well as sufficient prevention and treatment of physical comorbidity.
Abstract: Schizophrenia is often referred to as one of the most severe mental disorders, primarily because of the very high mortality rates of those with the disorder. This article reviews the literature on excess early mortality in persons with schizophrenia and suggests reasons for the high mortality as well as possible ways to reduce it. Persons with schizophrenia have an exceptionally short life expectancy. High mortality is found in all age groups, resulting in a life expectancy of approximately 20 years below that of the general population. Evidence suggests that persons with schizophrenia may not have seen the same improvement in life expectancy as the general population during the past decades. Thus, the mortality gap not only persists but may actually have increased. The most urgent research agenda concerns primary candidates for modifiable risk factors contributing to this excess mortality, i.e., side effects of treatment and lifestyle factors, as well as sufficient prevention and treatment of physical comorbidity.
589 citations
TL;DR: The updated theoretical model provides a framework for addressing significant questions regarding the phenomenology of disorders not explained in previous iterations of the original model.
Abstract: For over 50 years, Beck's cognitive model has provided an evidence-based way to conceptualize and treat psychological disorders. The generic cognitive model represents a set of common principles that can be applied across the spectrum of psychological disorders. The updated theoretical model provides a framework for addressing significant questions regarding the phenomenology of disorders not explained in previous iterations of the original model. New additions to the theory include continuity of adaptive and maladaptive function, dual information processing, energizing of schemas, and attentional focus. The model includes a theory of modes, an organization of schemas relevant to expectancies, self-evaluations, rules, and memories. A description of the new theoretical model is followed by a presentation of the corresponding applied model, which provides a template for conceptualizing a specific disorder and formulating a case. The focus on beliefs differentiates disorders and provides a target for treatme...
587 citations
TL;DR: A proposed framework in which sleep, and specifically rapid-eye movement (REM) sleep, supports a process of affective brain homeostasis, optimally preparing the organism for next-day social and emotional functioning is outlined.
Abstract: Rapidly emerging evidence continues to describe an intimate and causal relationship between sleep and emotional brain function. These findings are mirrored by long-standing clinical observations demonstrating that nearly all mood and anxiety disorders co-occur with one or more sleep abnormalities. This review aims to (a) provide a synthesis of recent findings describing the emotional brain and behavioral benefits triggered by sleep, and conversely, the detrimental impairments following a lack of sleep; (b) outline a proposed framework in which sleep, and specifically rapid-eye movement (REM) sleep, supports a process of affective brain homeostasis, optimally preparing the organism for next-day social and emotional functioning; and (c) describe how this hypothesized framework can explain the prevalent relationships between sleep and psychiatric disorders, with a particular focus on posttraumatic stress disorder and major depression.
577 citations
TL;DR: The overall goal of this review is to present a new understanding of substance use disorders as viewed by recent advances in behavioral economics.
Abstract: The field of behavioral economics has made important inroads into the understanding of substance use disorders through the concept of reinforcer pathology. Reinforcer pathology refers to the joint effects of (a) the persistently high valuation of a reinforcer, broadly defined to include tangible commodities and experiences, and/or (b) the excessive preference for the immediate acquisition or consumption of a commodity despite long-term negative outcomes. From this perspective, reinforcer pathology results from the recursive interactions of endogenous person-level variables and exogenous environment-level factors. The current review describes the basic principles of behavioral economics that are central to reinforcer pathology, the processes that engender reinforcer pathology, and the approaches and procedures that can repair reinforcement pathologies. The overall goal of this review is to present a new understanding of substance use disorders as viewed by recent advances in behavioral economics.
464 citations
TL;DR: Research to date suggests that the DSM-5 trait model provides reasonable coverage of personality pathology but also suggest areas for continued refinement, which provides a way of evolving psychopathology classification on the basis of research evidence as opposed to clinical authority.
Abstract: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents a watershed moment in the history of official psychopathology classification systems because it is the first DSM to feature an empirically based model of maladaptive personality traits. Attributes of patients with personality disorders were discussed by the DSM-5 Personality and Personality Disorders Work Group and then operationalized and refined in the course of an empirical project that eventuated in the construction of the Personality Inventory for DSM-5 (PID-5). We review research to date on the DSM-5 trait model, with a primary aim of discussing how this kind of research could serve to better tether the DSM to data as it continues to evolve. For example, studies to date suggest that the DSM-5 trait model provides reasonable coverage of personality pathology but also suggest areas for continued refinement. This kind of research provides a way of evolving psychopathology classification on the basis of res...
445 citations
TL;DR: An overview of changes in how the condition is conceptualized over the past two decades is provided, beginning with a brief discussion of the significance of classification in general before discussing Kanner's original paper and subsequent changes.
Abstract: Seven decades have elapsed since Leo Kanner described the syndrome he termed early infantile autism. Over this time, and particularly over the past two decades, noteworthy changes have occurred in how the condition is conceptualized. Here we provide an overview of these changes, beginning with a brief discussion of the significance of classification in general before discussing Kanner's original paper and subsequent changes. We touch on relevant issues, such as comorbidity, dimensional aspects of diagnosis and screening, and the complex issue of diagnosis relative to eligibility for services. Approaches to diagnosis have tended to swing from emphasizing overarching groups (lumping) to focusing on potentially distinct subgroups (splitting). Autism raises particular problems given the broad range of syndrome expression over age and developmental level. The most recent revision of the American Psychiatric Association's diagnostic taxonomy marks a significant departure from its predecessor and has been the fo...
212 citations
TL;DR: The evidence suggests that psychotherapy is generally effective with ethnic minorities, and treatment effects are fairly robust across cultural groups and problem areas, but support for cultural competence as a useful supplement to standard treatment remains equivocal at best.
Abstract: Despite compelling arguments for the dissemination of evidence-based treatments (EBTs), questions regarding their relevance to ethnically diverse populations remain. This review summarizes what is known about psychotherapy effects with ethnic minorities, with a particular focus on the role of cultural competence when implementing EBTs. Specifically, we address three questions: (a) does psychotherapy work with ethnic minorities, (b) do psychotherapy effects differ by ethnicity, and (c) does cultural tailoring enhance treatment effects? The evidence suggests that psychotherapy is generally effective with ethnic minorities, and treatment effects are fairly robust across cultural groups and problem areas. However, evidence for cultural competence is mixed. Ethnic minority-focused treatments frequently incorporate culturally tailored strategies, and these tailored treatments are mostly efficacious; yet support for cultural competence as a useful supplement to standard treatment remains equivocal at best. We also discuss research limitations, areas for future research, and clinical implications.
184 citations
TL;DR: In this paper, the authors review evidence for the validity of DSM-5 criteria and present a critical discussion of unsolved and new problems, and provide an update of mechanisms and interventions that have been empirically evaluated in somatoform disorders.
Abstract: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) changed the term “somatoform disorders” to “somatic symptom and related disorders” and further modified diagnostic labels and criteria. We review evidence for the validity of the new criteria, specifically of somatic symptom disorder (SSD), and present a critical discussion of unsolved and new problems. We also provide an update of mechanisms and interventions that have been empirically evaluated in somatoform disorders. For many mechanisms, it is unclear whether their role can be easily transposed to SSD. Therefore more research is needed on the similarities and differences between medically unexplained and medically explained conditions. To overcome the obvious shortcomings of the current classification, we offer a modification of this DSM-5 section as well as a crossover system to apply these criteria for somatic symptom and related disorders. This proposal allows working with DSM-5 but also continuing successful lin...
160 citations
TL;DR: These opportunities to explain attention-deficit/hyperactivity disorder (ADHD)-related risk of substance use disorder (SUD) remain available for study by considering characteristics of children with ADHD and factors affecting their outcomes side by side with overlapping variables in the developmental literature on SUD etiology.
Abstract: Many opportunities to explain attention-deficit/hyperactivity disorder (ADHD)-related risk of substance use disorder (SUD) remain available for study. We detail these opportunities by considering characteristics of children with ADHD and factors affecting their outcomes side by side with overlapping variables in the developmental literature on SUD etiology. Although serious conduct problems are a known contributor to ADHD-related risk of SUD, few studies have considered their emergence developmentally and in relation to other candidate mediators and moderators that could also explain risk and be intervention targets. Common ADHD-related impairments, such as school difficulties, are in need of research. Heterogeneous social impairments have the potential for predisposing, and buffering, influences. Research on neurocognitive domains should move beyond standard executive function batteries to measure deficits in the interface between cognitive control, reward, and motivation. Ultimately, maximizing prediction will depend, as it has in the SUD literature, on simultaneous consideration of multiple risk factors.
TL;DR: An overview of meta-analyses of the effects of prevention and promotion programs to prevent mental health, substance use, and conduct problems found small but significant changes that reduce depression, anxiety, antisocial behavior, and substance use.
Abstract: This review presents findings from an overview of meta-analyses of the effects of prevention and promotion programs to prevent mental health, substance use, and conduct problems. The review of 48 meta-analyses found small but significant changes that reduce depression, anxiety, antisocial behavior, and substance use. Furthermore, the results were sustained over time. Meta-analyses often found that the effects were heterogeneous. A conceptual model is proposed to guide the study of moderators of program effects in future meta-analyses, and methodological issues in synthesizing findings across preventive interventions are discussed.
TL;DR: It is concluded that neurodegenerative diseases can play an important role in future approaches to the assessment, prevention, and treatment of mental illness.
Abstract: Disruptions in emotional, cognitive, and social behavior are common in neurodegenerative disease and in many forms of psychopathology. Because neurodegenerative diseases have patterns of brain atrophy that are much clearer than those of psychiatric disorders, they may provide a window into the neural bases of common emotional and behavioral symptoms. We discuss five common symptoms that occur in both neurodegenerative disease and psychopathology (i.e., anxiety, dysphoric mood, apathy, disinhibition, and euphoric mood) and their associated neural circuitry. We focus on two neurodegenerative diseases (i.e., Alzheimer's disease and frontotemporal dementia) that are common and well characterized in terms of emotion, cognition, and social behavior and in patterns of associated atrophy. Neurodegenerative diseases provide a powerful model system for studying the neural correlates of psychopathological symptoms; this is supported by evidence indicating convergence with psychiatric syndromes (e.g., symptoms of disinhibition associated with dysfunction in orbitofrontal cortex in both frontotemporal dementia and bipolar disorder). We conclude that neurodegenerative diseases can play an important role in future approaches to the assessment, prevention, and treatment of mental illness.
TL;DR: Criticism of the attenuated psychosis syndrome concept is fully discussed, the APS concept is explicated; data relating to reliability, validity, and treatment are updated; the heterogeneity of APS is considered; and alternative views of the construct are presented with an emphasis on developmental pattern with timing for primary and secondary prevention and early treatment.
Abstract: Prodromal features of the schizophrenia syndrome have been described for a century, and work in the past two decades has produced a substantial literature based on these features to identify individuals at increased risk for developing a psychotic disorder Sometimes conceptualized as a “risk state” and sometimes as early manifestations of a “disorder,” the work has been conducted with several related but different constructs Early in the preparation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) public comment was sought on the proposal to create a new disorder termed attenuated psychosis syndrome (APS), and a range of issues emerged that generated interesting and important controversies In this review, these criticisms are fully discussed, the APS concept is explicated; data relating to reliability, validity, and treatment are updated; the heterogeneity of APS is considered; and alternative views of the construct are presented with an emphasis on developmenta
TL;DR: The structural changes in the six editions of the Diagnostic and Statistical Manual of Mental Disorders and the research that influenced those changes are discussed.
Abstract: The Diagnostic and Statistical Manual of Mental Disorders (DSM) was created in 1952 by the American Psychiatric Association so that mental health professionals in the United States would have a common language to use when diagnosing individuals with mental disorders. Since the initial publication of the DSM, there have been five subsequent editions of this manual published (including the DSM-III-R). This review discusses the structural changes in the six editions and the research that influenced those changes. Research is classified into three domains: (a) issues related to the DSMs as measurement systems, (b) studies of clinicians and how clinicians form diagnoses, and (c) taxonomic issues involving the philosophy of science and metatheoretical ideas about how classification systems function. The review ends with recommendations about future efforts to revise the DSMs.
TL;DR: The current article reviews extant literature on the intersection between poverty and the development of conduct problems (CP) in early childhood by expanding on the best-studied model, the family stress model, and focuses on the contribution of maternal depression, in terms of both compromising parenting quality and exposing children to higher levels of stressful events and contexts.
Abstract: The current article reviews extant literature on the intersection between poverty and the development of conduct problems (CP) in early childhood. Associations between exposure to poverty and disruptive behavior are reviewed through the framework of models emphasizing how the stressors associated with poverty indirectly influence child CP by compromising parent psychological resources, investments in children's welfare, and/or caregiving quality. We expand on the best-studied model, the family stress model, by emphasizing the mediating contribution of parent psychological resources on children's risk for early CP, in addition to the mediating effects of parenting. Specifically, we focus on the contribution of maternal depression, in terms of both compromising parenting quality and exposing children to higher levels of stressful events and contexts. Implications of the adapted family stress model are then discussed in terms of its implications for the prevention and treatment of young children's emerging CP.
TL;DR: There is inconclusive evidence of a link between antidepressants in late pregnancy and persistent pulmonary hypertension in the newborn, and extensive study finds that antidepressants cannot be considered major teratogens.
Abstract: Women in their reproductive years are at risk of experiencing depressive and anxiety disorders. As such, it is likely that pregnant women will undergo treatment with antidepressants. We review the risk of adverse birth outcomes and neonatal complications subsequent to antidepressant use in pregnancy. An inconsistent literature shows that antidepressant exposure is associated with shortened gestations and diminished fetal growth; these effects are small. Transitory neonatal signs are seen in some neonates after exposure to antidepressants in utero. No specific pattern of malformations has been consistently associated with antidepressants, with the possible exception of paroxetine and cardiac malformations. There is inconclusive evidence of a link between antidepressants in late pregnancy and persistent pulmonary hypertension in the newborn. Extensive study finds that antidepressants cannot be considered major teratogens. It is likely that confounding factors contribute to a number of the adverse effects found to be associated with antidepressant use in pregnancy.
TL;DR: The authors summarizes the history, updates reviews, and incorporates new research findings into an integrative scheme for conceptualizing personality pathology in childhood and adolescence. Implications of this model for assessment, future research, and intervention are discussed.
Abstract: Antecedents of personality disorder in childhood and adolescence have been a neglected area in official taxonomies of mental disorders such as the International Classification of Diseases or the different editions of the Diagnostic and Statistical Manual of Mental Disorders. An evolving research field, however, underscores the importance of antecedents for understanding psychopathology and personality pathology in adulthood. The current article summarizes the history, updates reviews, and incorporates new research findings into an integrative scheme for conceptualizing personality pathology in childhood and adolescence. Implications of this model for assessment, future research, and intervention are discussed.
TL;DR: The Institute of Medicine 2011 standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options.
Abstract: Clinical practice guidelines (CPGs) are intended to improve mental, behavioral, and physical health by promoting clinical practices that are based on the best available evidence. The American Psychological Association (APA) is committed to generating patient-focused CPGs that are scientifically sound, clinically useful, and informative for psychologists, other health professionals, training programs, policy makers, and the public. The Institute of Medicine (IOM) 2011 standards for generating CPGs represent current best practices in the field. These standards involve multidisciplinary guideline development panels charged with generating recommendations based on comprehensive systematic reviews of the evidence. The IOM standards will guide the APA as it generates CPGs that can be used to inform the general public and the practice community regarding the benefits and harms of various treatment options. CPG recommendations are advisory rather than compulsory. When used appropriately, high-quality guidelines can facilitate shared decision making and identify gaps in knowledge.
TL;DR: The phenomenology, prevalence, and risk factors of patients with PD, as well as new insights from functional imaging studies, strengthening the incentive salience hypothesis, are discussed, and therapeutic guidelines for the management of ICBs in PD are given.
Abstract: Impulsive-compulsive behaviors (ICBs) in Parkinson's disease (PD) are a common and devastating side effect of dopamine replacement therapy. In this review we describe the phenomenology, prevalence, and risk factors of patients with PD. Results of behavioral studies assessing the neuropsychological profile of patients with PD emphasize that the ICBs, which are behavioral addictions, are not hedonically motivated. Rather, other factors such as the inability to cope with uncertainty may be triggering ICBs. New insights from functional imaging studies, strengthening the incentive salience hypothesis, are discussed, and therapeutic guidelines for the management of ICBs in PD are given.
TL;DR: It is demonstrated that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives.
Abstract: This article reviews the literature on interventions and services for depression and suicide prevention among adolescents, with the goals of placing this science within the context of currently changing health care environments and highlighting innovative models for improving health and mental health. We examine the challenges and opportunities offered by new initiatives and legislation designed to transform the US health and mental health care systems; summarize knowledge regarding the treatment of depression and suicidality/self-harm in adolescents; and describe innovative models for partnering with health systems and communities. This review demonstrates that treatment models and service delivery strategies are currently available for increasing evidence-based care, particularly for depression, and concludes with recommendations for future research and quality improvement initiatives aimed at inspiring additional efforts to put science to work, bridge science and community practice, and develop strategies for partnering with communities to improve care, mental health, and well-being among adolescents.
TL;DR: The epidemiological, neurobiological, and genetic evidence linking cannabinoids and psychosis is reviewed, the quality of the evidence is assessed, and the most robust findings are integrated into a neurodevelopmental model of cannabis-induced psychosis.
Abstract: Epidemiological studies have shown that the association between cannabis and psychosis is robust and consistent across different samples, with compelling evidence for a dose-response relationship. Because longitudinal work indicates that cannabis use precedes psychotic symptoms, it seems reasonable to assume a causal relationship. However, more work is needed to address the possibility of gene-environment correlation (for example, genetic risk for psychosis causing onset of cannabis use). Moreover, knowledge about underlying biological mechanisms linking cannabis use and psychosis is still relatively limited. In order to understand how cannabis use may lead to an increased risk for psychosis, in the present article we (a) review the epidemiological, neurobiological, and genetic evidence linking cannabinoids and psychosis, (b) assess the quality of the evidence, and finally (c) try to integrate the most robust findings into a neurodevelopmental model of cannabis-induced psychosis and identify the gaps in k...
TL;DR: In this review, relevant research is synthesized to help resolve the challenge of high-risk juveniles in the juvenile justice system in a manner that is consistent with the law's core principles.
Abstract: After a distinctly punitive era, a period of remarkable reform in juvenile crime regulation has begun. Practical urgency has fueled interest in both crime reduction and research on the prediction and malleability of criminal behavior. In this rapidly changing context, high-risk juveniles—the small proportion of the population where crime becomes concentrated—present a conundrum. Research indicates that these are precisely the individuals to treat intensively to maximize crime reduction, but there are both real and imagined barriers to doing so. Mitigation principles (during early adolescence, ages 10–13) and institutional placement or criminal court processing (during mid-late adolescence, ages 14–18) can prevent these juveniles from receiving interventions that would best protect public safety. In this review, we synthesize relevant research to help resolve this challenge in a manner that is consistent with the law's core principles. In our view, early adolescence offers unique opportunities for risk red...
TL;DR: There are two divergent viewpoints on the phenomenology and outcome of bipolar I (BP I) disorder in youth: rates of conservatively diagnosed BP I are lower both in community studies of youths than in adults and from liberally defined BP I in youths.
Abstract: There are two divergent viewpoints on the phenomenology and outcome of bipolar I (BP I) disorder in youth. Disparities evolved as unintended consequences from investigators' inconsistencies both in translating the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III, DSM-III-R, and DSM-IV criteria and in operationalizing them differently in their standardized assessments. Rates of conservatively diagnosed BP I are lower both in community studies of youths than in adults and from liberally defined BP I in youths. Rates of co-occurring attention-deficit hyperactivity disorder (ADHD) are lower in conservatively than liberally defined children and adolescents with BP I. Rates of both BP I and of ADHD are lower in offspring of BP I probands, and outcome more closely approximates that of adults with BP I in conservatively versus liberally defined children and teens with BP I. Both perspectives can claim evidence for reliability and validity that support their positions. However, the samples are so di...
TL;DR: Judging from a thin slice of another's nonverbal behavior could provide a complementary tool for the clinician's toolbox for certain traits and disorders.
Abstract: Clinicians make a variety of assessments about their clients, from judging personality traits to making diagnoses, and a variety of methods are available to do so, ranging from observations to structured interviews. A large body of work demonstrates that from a brief glimpse of another's nonverbal behavior, a variety of traits and inner states can be accurately perceived. Additionally, from these “thin slices” of behavior, even future outcomes can be predicted with some accuracy. Certain clinical disorders such as Parkinson's disease and facial paralysis disrupt nonverbal behavior and may impair cli-nicians' ability to make accurate judgments. In certain contexts, personality disorders, anxiety, depression, and suicide attempts and outcomes can be detected from others' nonverbal behavior. Additionally, thin slices can predict psychological adjustment to divorce, bereavement, sexual abuse, and well-being throughout life. Thus, for certain traits and disorders, judgments from a thin slice could provide a co...
TL;DR: The theoretical background underlying the evaluation of diagnoses, possible designs of reliability studies, estimation of the reliability coefficient, the standards for assessment of reliability, and strategies for improving reliability without compromising validity are discussed.
Abstract: Reliability of clinical diagnosis is essential for good clinical decision making as well as productive clinical research. The current review emphasizes the distinction between a disorder and a diagnosis and between validity and reliability of diagnoses, and the relationships that exist between them. What is crucial is that reliable diagnoses are essential to establishing valid diagnoses. The present review discusses the theoretical background underlying the evaluation of diagnoses, possible designs of reliability studies, estimation of the reliability coefficient, the standards for assessment of reliability, and strategies for improving reliability without compromising validity.
TL;DR: How treatment efficacy is systematically overstated and treatment-related harms are understated in the scientific literature is described and suggestions are provided to improve public access to underlying safety and efficacy data and for the FDA to potentially improve its review process.
Abstract: Data on the efficacy and safety of psychiatric medicines should form the foundation of evidence-based treatment practices. The US Food and Drug Administration (FDA) reviews such data in determining whether to approve new treatments, and the published literature serves as a repository for evidence on treatment benefits and harms. We describe the FDA review of clinical trials, examining the underlying logic and legal guidelines. Several FDA reviews provide evidence that the agency requires only minimal efficacy for psychiatric drugs. Further, in some instances, the FDA has relied on secondary rather than primary outcomes and has discounted the findings of negative studies in its review of antidepressant and antipsychotic medications. The published literature provides another lens into the safety and efficacy of treatments. We describe how treatment efficacy is systematically overstated and treatment-related harms are understated in the scientific literature. Suggestions are provided to improve public access to underlying safety and efficacy data and for the FDA to potentially improve its review process.
TL;DR: The structure of the internship placement process, including and beyond the APPIC match, is discussed, and the reasons for the failed efforts are identified, which lie principally in the varied standards for an acceptable internship among doctoral programs.
Abstract: The internship is an essential part of doctoral training in professional psychology. Most students access internships through the annual match sponsored by the Association of Psychology Postdoctoral and Internship Centers (APPIC). For two decades the match has seen an increasing shortfall of internship positions relative to applicants, exceeding 650 unmatched clinical students as of 2013. Efforts to solve this problem have not met appreciable success. This review discusses the structure of the internship placement process, including and beyond the APPIC match, and identifies the reasons for the failed efforts, which lie principally in the varied standards for an acceptable internship among doctoral programs. Efforts to establish a common standard and the need for a governance structure to enforce whatever standard is agreed upon are discussed. Projections for the future of the placement process and the imbalance are sketched, and links to other issues in the field are briefly reviewed.