Suicide

Suicide is a leading cause of death and is preventable. This chapter identifies landmark papers from three areas within the field of suicide prevention that are important for trainees, experienced clinicians, and policymakers alike. Firstly, it reviews papers on evidence-based suicide prevention strategies. Physician education, pharmacological and psychotherapy treatments, school-based suicide prevention programmes, and means of suicide restriction are found to be effective in preventing suicidal behaviours. Suicide prevention strategies that require further research on efficacy are identified, along with directions for future research. Secondly, several papers are analysed providing evidence that talking about suicide does not cause iatrogenic effects. Suicide research and prevention should not be hindered due to unsubstantiated concerns. Lastly, a paper discussing the genetics of suicidal behaviour provides an understanding of the diathesis of suicide. These landmark papers highlight the importance of suicide prevention and inform future research.

Forensic psychiatry

Forensic psychiatry exists within the ever-changing social and conceptual space where issues of law and mental state meet. Though generally associated with issues such as the insanity defence, fitness to stand trial, and the like, forensic psychiatry includes within its ambit many aspects of everyday clinical practice—issues such as risk prediction, antisocial personality disorder, decisional capacity, and identifying and resolving ethical conflicts. Rather than focusing on topics of little practical interest to the general clinician, articles for this chapter were chosen to address these everyday issues.

Psychiatric ethics

As psychiatric practice becomes more embedded in social, cultural, and financial networks, it is hardly surprising that the scrutiny of psychiatrists by organizations and institutions grows almost daily. This chapter focuses on the scrutiny of psychiatric ethics. Seven papers are reviewed, ranging from the mid-1950s up to 2009. Topics considered include: professional relationships between psychiatrists, physician impairment, confidentiality in the context of dangerousness, standard-of-care disputes, assessments of competency and decision-making capacity, the history and ethics of psychosurgery and neuromodulation, treatment refusal in chronically mentally ill patients, and conflicts of interest in clinical practice guideline authorship. Each paper is summarized with background information, methods, results, and a critical discussion of its significance.

Electroconvulsive therapy

This chapter on electroconvulsive therapy (ECT) surveys the history of this effective treatment modality in psychiatry. It reviews the first publication introducing ECT, which was followed by rapid expansion throughout the world. Next, the important topic of memory impairment is reviewed. Thereafter, it discusses the technical modifications that resulted in less memory impairment, most notably unilateral electrode placement and brief-pulse square-wave electrical stimulation. The publication of a placebo-controlled trial establishing efficacy using modern research methods is also discussed. Finally, a controlled trial of continuation ECT is presented, which touches on the need to prevent relapse. The chapter can be appreciated by readers of any background, whether medical or not.

Psychodynamic therapy

From its early origins in the study of repressed memories and unconscious conflict to its more recent iterations as brief, relationship-focused treatments for increasingly diverse individuals, psychodynamic psychotherapy has adapted itself to the changing needs of its patients, practitioners, and the larger culture. At the same time, a clear tradition links the distinct phases of dynamic therapy. This chapter reviews seven articles that represent major themes and shifts in the work of dynamic therapy over the 125 years of its history. It presents the background for the genesis of each paper, the ways that the article responded to the context in which it arose, and the implications the article had for psychodynamic practice. Lastly, the chapter highlights how these landmark papers point to the continuing challenges and evolution of dynamic psychotherapy.

Pharmacotherapy of anxiety and related disorders

Anxiety disorders are the most prevalent of the mental disorders, and good translational models of these conditions encourage pharmacotherapy studies. This chapter discusses six randomized clinical trials that have contributed significantly to the pharmacotherapy of anxiety and related disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and social anxiety disorder. Although any such list is necessarily incomplete, these selections may shed light on early and ongoing challenges in the field and on key advances to date. After reviewing these foundational papers, the advances they represent, and the work that they have given impetus to, the chapter closes by considering future directions in work on the pharmacotherapy of anxiety and related disorders.

Psychosocial rehabilitation

Psychosocial rehabilitation (synonymously referred to as psychiatric rehabilitation) is a field and service within mental health systems that shifted the treatment focus from symptom control to social inclusion by functional recovery. It aims to help individuals with severe mental illness live in the community as independently as possible. Psychosocial rehabilitation (PR) developed in the 1970s, when psychiatric reform, including the process of deinstitutionalization, had already paved the way to more responsive and balanced provision of mental health care. This chapter outlines major developments in and obstacles to the reform in European and other high-income countries. It introduces the evolving principles of PR and presents evidence on important models of care, such as assertive community treatment (ACT) and individual placement and support (IPS), that share the objectives of PR to improve integration of people with severe mental illness into the labour market and society in general.

Psychological and social factors

This chapter on psychological and social factors reviews landmark papers addressing the social and psychological contributors to mental disorders and wellness across a range of psychiatric conditions. These papers provide a foundation for understanding the role of stress and critical social environments in psychoses, the cognitive factors that characterize depressive thinking, the impact of environmental trauma on the development of personality conditions and suicidal behaviour, and important social avenues for protecting against risk and facilitating human resilience. Collectively, this early and landmark literature provides compelling evidence for the social and psychological contributors to the development and maintenance of many psychiatric conditions, and illustrates that garnering a better understanding of such factors has led to numerous advances in the prevention and treatment of mental disorders.

Non-convulsive brain stimulation

Before 1990, neurologists and psychiatrists could not readily image or examine (except at death) their main organ of study, the brain, causing clinical neuroscience to lag behind the rest of medicine. In the past 30 years, new brain-imaging techniques (positron emission tomography (PET) and magnetic resonance imaging (MRI)) have allowed neuropsychiatrists to play catch-up, equipped with a more detailed and complex understanding of functional neuroanatomy. Researchers could then theorize about how circuit-based dysfunction might cause psychiatric diseases. In addition to the tools of electroconvulsive therapy (ECT) and brain surgery, we now have a rapidly expanding therapeutic toolkit of non-invasive brain-stimulation devices. This chapter presents a representative landmark imaging paper from the functional imaging revolution, and four device-based papers (two on transcranial magnetic stimulation (TMS), and one each on transcranial alternating current stimulation (tACS) and vagus nerve stimulation (VNS)). These papers broadly cover the path that led to the exciting current and future possibilities for therapeutic non-invasive brain stimulation.

Social and community psychiatry

Social and community psychiatry is a subspecialty within psychiatry focused on identifying and treating mental health disorders in community-based settings. This subspecialty emerged as a direct consequence of several factors including deinstitutionalization, increased focus on biological aetiologies and treatment of mental health disorders, and the change in the nature of funding for mental healthcare. This chapter highlights several important issues related to community-based delivery of psychiatric care including: accurate assessment of the prevalence of mental health disorders and use of mental health services across all components of the mental health system of care; the evolution of office-based psychiatric practice, from lengthier psychotherapy visits toward shorter visits and greater use of psychotropic medications; the evolution of depression treatment in primary care; and understanding the relationship between culture and psychiatric illness.