Psychiatric Research: 2006

I have just returned from the 2006 meeting of The American College of Psychiatrists. Their scientific program focused on “stress,” a topic of longstanding interest to psychoanalysts, and provided an excellent overview of how psychiatrists think about stress in 2006, their other research interests, and what scientific questions they are asking.

One fundamental conceptual point was repeatedly emphasized. Stress has both good and bad effects. The acute response to stress has many highly adaptive features while the response to chronic or sustained stress is often maladaptive. A repeated finding in studies employing brain-imaging methods was that organisms (both animal and human) exposed to chronic stress had evidence of shrinking of the hippocampus. This involved a loss of neurons, interference with the normal growth of new neurons, and abnormalities in the dendrites of existing neurons. Chronic exposure to stress hormones appears to be at least one of the intervening variables. Stress affects the brain, and, although we don't yet know the optimal amount of stress for brain health, it has become clear that too much stress makes for trouble. The discussion emphasized the complexity of causal inference in these largely cross-sectional studies—which brain characteristics predispose to stress, which result from stress, what is the role of genetic factors, and what are the essential characteristics that make an experience “stressful.” It will come as no surprise to psychoanalysts that the individual's interpretation of an experience and the brain characteristics that influence that interpretation seem to be as important as the stress response pattern in determining the effects of stress.

There was extended discussion of one specific stress depression, and its effect on cardiovascular disease. There is powerful evidence that depression aggravates ischemic heart disease, is a major risk factor in the etiology of heart disease, and also a clear suggestion that the treatment of depression reduces the morbidity and mortality of the heart disease, independently of its effect on mood. This last issue is complicated by the fact that the most commonly used anti-depressants have a direct effect on clotting mechanisms.

One fundamental conceptual point was repeatedly emphasized. Stress has both good and bad effects. The acute response to stress has many highly adaptive features while the response to chronic or sustained stress is often maladaptive.

Interest in stress has become linked to interest in early childhood trauma and the lifelong effects of childhood traumatic experience. The discussion of trauma included an interesting suggestion for the planners of the next DSM—that disorders viewed as the sequelae of trauma be clustered together, including acute stress disorder, post-traumatic stress disorder, depression, dissociative disorder (including dissociative identity or multiple personality disorder), and borderline personality disorder. Of course, to a psychoanalyst the familiar question arises of whether these syndromes predispose to trauma, are the result of trauma, or are, along with trauma, the result of some basic underlying predisposition.

The meeting included updates on three large ongoing studies of the treatment of schizophrenia, bipolar disease, and depression. There are important differences among the studies, and for the most part they deal with patients not usually seen by psychoanalysts. However, they also have a number of similarities and a strongly optimistic message for future research in psychoanalytic treatment. The studies are all large (combined, the three involve almost 10,000 patients), multi-site, and funded by NIH rather than by the pharmaceutical industry. They are largely “effectiveness” studies (the treatment of typical patients in typical settings) rather than “efficacy” studies (the treatment of highly selected patients under optimal research conditions). They differ from most earlier studies by following patients over a longer period of time, tracing the changes in treatment strategy if the initial treatment is not effective, and looking at a wider range of outcomes in addition to symptom relief. In brief, these studies ask, “How can we best treat these patients?” rather than, “Does this drug meet requirements for FDA approval?” Future systematic evaluation of psychoanalytic treatments will also be multicenter, will involve following complex courses of treatment, and will involve multiple outcomes rather than simply symptom relief; that is, they will also be “effectiveness” rather than “efficacy” studies. Perhaps, reflecting their public health importance, they may also be publicly funded.

There was little on the program that was directly about psychoanalysis, accurately reflecting the status of psychoanalysis in contemporary psychiatric research. However, there were a number of psychoanalysts in attendance, again accurately reflecting the interest of contemporary psychoanalysts in building bridges and developing the conceptual and methodologic infrastructure that will enrich both psychiatric and psychoanalytic inquiry as we move on.