Vitamin B12 Supplementation in Psychiatric Practice.

PURPOSE OF REVIEW: Vitamin B12 (B12, cobalamin) deficiency has been associated with neuropsychiatric symptoms, suggesting a role for B12 supplementation both as a treatment for psychiatric symptoms due to B12 deficiency and as an augmentation strategy for pharmacological treatments of psychiatric disorders. This critical review discusses the major causes of B12 deficiency, the range of psychiatric and non-psychiatric manifestations of B12 deficiency, the indications for testing B12 levels, and the evidence for B12 supplementation for major psychiatric disorders. RECENT FINDINGS: We find that high-quality evidence shows no benefit to routine B12 supplementation for mild depressive symptoms or to prevent depression. There is very limited evidence on the role of B12 supplementation to augment antidepressants. No high-quality evidence to date suggests a role for routine B12 supplementation in any other major psychiatric disorder. No formal guidelines indicate when clinicians should test B12 levels for common psychiatric symptoms, in the absence of major risk factors for deficiency or cardinal symptoms of deficiency. No robust evidence currently supports routine B12 supplementation for major psychiatric disorders. However, psychiatrists should be aware of the important risk factors for B12 deficiency and should be able to identify symptoms of B12 deficiency, which requires prompt testing, medical workup, and treatment. Testing for B12 deficiency should be considered for atypical or severe psychiatric presentations.

Integrating psychosocial concepts into psychopharmacology training: a survey study of program directors and chief residents.

A growing body of evidence suggests that psychiatric medication outcomes are shaped significantly by psychological and social factors surrounding the prescribing process. Little, however, is known about the extent to which psychiatry programs integrate this evidence base into residency training or the methods by which this is accomplished. Psychiatry residency program directors and chief residents participated in an exploratory online survey to establish how psychosocial factors known to impact medication outcomes are integrated into psychopharmacology education. While participants highly valued the importance of psychosocial factors in the prescribing process, there was limited emphasis of these factors in psychopharmacology training. Additionally, some teaching methods that could advance understanding of complex interactions in the psychopharmacology relationship were found to be underutilized. Given that medication outcomes are significantly influenced by psychosocial factors, psychiatric educators have a responsibility to teach residents about the evidence base available. Residents exposed to this evidence base will be better equipped to manage the complexities of the psychopharmacology role. The results of this study offer clues as to how psychosocial factors may be more fully integrated into residency psychopharmacology training.

Teaching all the evidence bases: reintegrating psychodynamic aspects of prescribing into psychopharmacology training.

The discipline of psychiatry appears poised at the edge of a paradigm shift. Enthusiasm about psychopharmacological treatments and neuroscientific understandings is giving way to a sobering recognition of the limitations of current biologically oriented approaches. Psychiatry training programs have both an opportunity and a responsibility to address the challenges presented by the evidence. Although the average psychiatrist would profess a biopsychosocial ideal, an examination of our practice, journals, and training curricula suggests that we still have a long way to go before we employ a truly integrated model. There is a compelling, though oft-neglected evidence base demonstrating that pharmacologic treatment outcomes are as dependent on psychological and interpersonal factors as on medical ones. In order to maximize our usefulness to patients, psychiatry must embrace more complex and integrated understandings, transcending reductionistic models that promote mind-body splits. This article explores some of the costs of a model that places disproportionate emphasis on a biological framework. Relevant evidence bases are reviewed that demonstrate the utility of emphasizing the psychology of psychopharmacology. Implications for psychiatric training are considered, and suggestions are made for better integrating meaning factors into psychopharmacology education.

How (not what) to prescribe: nonpharmacologic aspects of psychopharmacology.

Despite advances in psychopharmacology over the past several decades, treatment outcomes for depression have not substantially improved. Depression is not being eradicated. If anything, the evidence suggests that the problem of depression and treatment-resistant depression is growing, not shrinking. As biologically reductionistic approaches dominate psychiatric practice, patient care has steered away from considering the potent effects of meaning and relationships in the psychopharmacologic treatment of our patients. By construing patients as passive recipients of concrete, specific, and straightforward medical interventions, the field has succumbed to a delusion of precision, and unwittingly moved into an era of treatment resistance in which some of our most potent tools are wasted. In such a model we have settled for treating a disorder rather than a whole person. This article is intended as a step toward remedy. Meaning effects, therapeutic alliance, ambivalence, and patient autonomy, among others, have a powerful and measurable impact on the use of medication that should be considered if we are to treat the whole person. Bringing these elements together into a coherent model of treatment, however, is only a starting point. More research is needed if we are to understand the effects these elements have when used together in an integrated model that is simultaneously personalized and evidence-based.

The role of personal therapy in psychiatric residency training: a survey of psychiatry training directors.

OBJECTIVE: The authors examine the current place of personal therapy for residents in U.S. training programs. METHODS: All U.S. training directors were provided an anonymous survey assessing current attitudes and practices with regard to personal therapy and training director perception of their residents' use of therapy. RESULTS: Training directors generally believed that personal therapy is useful during training, but fewer than one-third of residents seek therapy during residency. Program characteristics associated with the use of personal therapy by residents included training director beliefs in the value of therapy to mitigate personal problems, active encouragement by the training director to seek therapy, programmatic supports to reduce the cost of therapy to residents, and geographic location. CONCLUSION: The proportion of residents seeking personal therapy is falling, despite training directors' perceptions of the benefit of therapy to residents. This study identified practices promoting a culture in which residents seek therapy.

Teaching the prescriber's role: the psychology of psychopharmacology.

OBJECTIVE: The author examines one aspect of the psychopharmacology curriculum: the psychology of psychopharmacology. METHOD: Drawing from his experience teaching this subject to trainees at many different levels and from an emerging evidence base suggesting that psychosocial factors in the doctor-patient relationship may be crucial for medication effectiveness, the author explores the importance of this often overlooked aspect of pharmacotherapy. Several methods for teaching the integration of meaning and medication are examined. RESULTS: Generally, residents receiving thorough instruction in the psychology of psychopharmacology believe that they are not only better equipped to integrate psychotherapy and medications, but that this instruction enhances their skills as psychopharmacologists and psychotherapists. CONCLUSION: Teaching the psychodynamics of psychopharmacology addresses not only residents' needs to become more effective prescribers, but, in part, it may also address predictable developmental crises in residency.