Comments on "cyclical swings" by Professor Hannah Decker: The underappreciated "solid center" of psychiatry.

The history of psychiatry is characterized by some deep ideological and conceptual divisions, as adumbrated in Professor Hannah Decker's essay. However, the schism between "biological" and "psychosocial" models of mental illness and its treatment represents extreme positions among some psychiatrists-not the model propounded by academic psychiatry or its affiliated professional organizations. Indeed, the "biopsycho-social model" (BPSM) developed by Dr. George L. Engel has been, and remains, the foundational model for academic psychiatry, notwithstanding malign market forces that have undermined the BPSM's use in clinical practice. The BPSM is integrally related to "centralizing" and integrative trends in American psychiatry that may be traced to Franz Alexander, Karl Jaspers, and Engel himself, among others. This "Alexandrian-Jaspersian-Engelian" tradition is explored in relation to Professor Decker's "cyclical swing" model of psychiatry's history.

Mind-language in the age of the brain: is "mental illness" a useful term?

The term "mental illness" has been criticized on a variety of grounds, most notably by those who have argued that the term is merely a "myth" or a "metaphor." Some have argued that if and when so-called mental illnesses are exhaustively explained by disturbed brain function or structure, we will no longer need the term "mental illness," on the supposition that neuropathology and psychopathology are mutually exclusive constructs. The author argues that, on the contrary, the locution "mental illness" is not rendered useless or unnecessary when neuropathology is discovered, nor is the term "mental illness" a metaphor. Rather, it is an instance of "ordinary language" that we apply quite literally to certain types of suffering and incapacity in the realm of thought, emotion, cognition, and behavior. Although its use carries the risk of perpetuating mind-body dualism and it may be misused as a pejorative label, "mental illness" is likely to remain a useful and meaningful descriptive term, even as we discover the neurobiological underpinnings of psychiatric illness.

The Bereavement Exclusion and DSM-5: An Update and Commentary.

The removal of the bereavement exclusion in the diagnosis of major depression was perhaps the most controversial change from DSM-IV to DSM-5. Critics have argued that removal of the bereavement exclusion will "medicalize" ordinary grief and encourage over-prescription of antidepressants. Supporters of the DSM-5's decision argue that there is no clinical or scientific basis for "excluding" patients from a diagnosis of major depression simply because the condition occurs shortly after the death of a loved one (bereavement). Though bereavement-related grief and major depression share some features, they are distinct and distinguishable conditions. Bereavement does not "immunize" the patient against a major depressive episode, and is in fact a common precipitant of clinical depression. Recognizing major depression in the context of recent bereavement takes careful clinical judgment, and by no means implies that antidepressant treatment is warranted. But given the serious risks of unrecognized major depression-including suicide- eliminating the bereavement exclusion from DSM-5 was, on balance, a reasonable decision.

Bereavement: course, consequences, and care.

This paper discusses each of several potential consequences of bereavement. First, we describe ordinary grief, followed by a discussion of grief gone awry, or complicated grief (CG). Then, we cover other potential adverse outcomes of bereavement, each of which may contribute to, but are not identical with, CG: general medical comorbidity, mood disorders, post-traumatic stress disorder, anxiety, and substance use.

Addressing risks to advance mental health research.

IMPORTANCE: Risk communication and management are essential to the ethical conduct of research, yet addressing risks may be time consuming for investigators and institutional review boards may reject study designs that seem too risky. This can discourage needed research, particularly in higher-risk protocols or those enrolling potentially vulnerable individuals, such as those with some level of suicidality. Improved mechanisms for addressing research risks may facilitate much needed psychiatric research. OBJECTIVE: To provide mental health researchers with practical approaches to (1) identify and define various intrinsic research risks, (2) communicate these risks to others (eg, potential participants, regulatory bodies, and society), (3) manage these risks during the course of a study, and (4) justify the risks. EVIDENCE REVIEW: As part of a National Institute of Mental Health-funded scientific meeting series, a public conference and a closed-session expert panel meeting were held on managing and disclosing risks in mental health clinical trials. The expert panel reviewed the literature with a focus on empirical studies and developed recommendations for best practices and further research on managing and disclosing risks in mental health clinical trials. No institutional review board-review was required because there were no human subjects. FINDINGS: Challenges, current data, practical strategies, and topics for future research are addressed for each of 4 key areas pertaining to management and disclosure of risks in clinical trials: identifying and defining risks, communicating risks, managing risks during studies, and justifying research risks. CONCLUSIONS AND RELEVANCE: Empirical data on risk communication, managing risks, and the benefits of research can support the ethical conduct of mental health research and may help investigators better conceptualize and confront risks and to gain institutional review board-approval.

Grief, depression, and the DSM-5.

Based on a review of the best available evidence and the importance of providing clinicians an opportunity to ensure that patients and their families receive the appropriate diagnosis and the correct intervention without necessarily being constrained by a somewhat arbitrary 2-month period of time, the DSM-5 Task Force recommended eliminating the "bereavement exclusion" (BE) from the diagnosis of major depressive disorder. This article reviews the initial rationale for creating a BE in DSM-III, reasons for not carrying the BE into DSM-5, and sources of continued controversy. The authors argue that removing the BE does not "medicalize" or "pathologize" grief, "stigmatize" bereaved persons, imply that grief morphs into depression after 2 weeks, place any time limit on grieving, or imply that antidepressant medications should be prescribed. Rather, eliminating the BE opens the door to the same careful attention that any person suffering from major depressive disorder deserves and allows the clinician to provide appropriate education, support, hope, care, and treatment.