Editors Select AJP Articles That Stood Out in 2016

The editorial board of the American Journal of Psychiatry works throughout the year to publish articles that they believe are most important to the mental health profession at large. As the year closes, AJP’s editor and deputy editors, along with the editor of the accompanying AJP Resident’s Journal, like to revisit published articles that they found personally interesting or relevant. In 2016, nine articles covering a range of topics were highlighted as top picks in an editorial appearing in the December issue of the journal; a selection of these are included below.

Mental Health Services for Refugees

AJP features many contributions from foreign researchers each year. In 2016 one-quarter of all published articles were written by authors residing outside of the United States. In recognition of APA’s international colleagues, the journal launched a new section this past year titled “Perspectives in Global Mental Health.”

AJP Editor-in-Chief Robert Freedman, M.D., chose to close 2016 by reminding readers of one of the perspectives that was included in this section titled “A Compounding Mental Health Crisis: Reflections From the Greek Experience With Syrian Refugees.”

The article, written by Dimitris Anagnostopoulos, M.D., of the University of Athens and his colleagues, described the clinical assessment of a troubled 14-year-old Syrian boy named “Amed,” who is living in Greece with his father.

As Anagnostopoulos wrote, the case of Amed is a microcosm of the pressures facing mental health services in his home country. Greece hosts a large population of refugees from Syria and other countries. They face alienation and hardship and need good health services, but the recent financial crisis has reduced resources to natives and immigrants alike.

In the face of these dual crises, the authors discussed how diagnosing the mental health of refugee patients like Amed requires a multimodal strategy that considers psychological, historical, and cultural issues. They also noted that mental health professionals need to not only support natives and refugees with effective treatments, but also stand up for them as advocates for their rights.

Fortunately, in the end, Amed was successfully diagnosed with posttraumatic stress disorder and provided treatment at a nongovernmental day center that provides culturally competent care to migrants.

“The determination of these psychiatrists to continue providing the best clinical care possible and to write about the experience, regardless of difficult conditions, earns my respect and admiration,” Freedman wrote.

The United States is also a destination for refugees, including many from the lesbian, gay, bisexual, or transgender (LGBT) communities fleeing intolerant areas. In the editor’s choice of the AJP Residents’ Journal, psychiatry resident Mark Messih, M.D., of Drexel University discusses the vulnerability of LGBT refugees, both from pre-flight stressors such as oppression and violence and post-flight problems of assimilation and culture shock.

Messih noted that with the high degree of trauma many LGBT refugees have experienced, mental health professionals should focus on establishing a safe environment and seek to empower these patients.

Residents’ Journal editor Katherine Pier, M.D., concurred: “If the United States aspires to become home for these patients, we should not only prevent further detriment but also provide an environment that allows refugees to heal.”

Assessing the Life Course of Borderline Personality Disorder

Despite the recognition that many people can experience mental illness throughout their lives, most studies focus on the acute effects of treatment, which is why AJP Deputy Editor Robert Michels, M.D., found the 2016 report from Mary Zanarini, Ed.D., of Harvard Medical School and colleagues on the 16-year trajectory of borderline personality disorder (BPD) symptoms particularly interesting.

A total of 290 BPD inpatients and 72 comparison inpatients were recruited and assessed every two years for this 16-year effort. Of this group, 231 BPD patients and 58 comparison patients were interviewed in all eight assessments, and more than 4,600 individual clinical assessments were completed.

“No single clinician, and very few groups, could accumulate that much experience, and each assessment was standardized and involved instruments of known reliability,” Michels wrote.

The clinical analysis revealed that BPD patients experience two clusters of symptoms: chronic “temperamental” symptoms that remit briefly but recur regularly (such as depression or loneliness), and “acute” symptoms (such as affective instability or self-mutilation) that are more dramatic but remit frequently and recur much less frequently.

“It seems that the affective symptoms of the disorder are the most chronic—briefly remitting and then recurring,” the authors wrote. “This suggests that clinicians should not be discouraged that these symptoms persist or try to address them with very aggressive polypharmacy that can have negative health consequences. … Rather, helping patients to accept these feelings may be the most useful strategy.”

“A picture of the natural course of the disorder, such as this one, is essential as a basis for planning, conducting, or evaluating a treatment,” Michels wrote.

Tracking Children of Depressed Parents for Over Three Decades

A study tracking the long-term mental health outcomes of children with depressed parents was a top pick of AJP Deputy Editor A. John Rush, M.D. Myrna Weissman, Ph.D., of Columbia University and her colleagues found that children with one or more depressed parents had a greater risk of depression and a typically earlier onset of the disorder.

Weissman and colleagues performed diagnostic assessments of children who had at least one parent diagnosed with major depression at the start of the study, and again two, 10, 20, 25, and 30 years later. In addition to being one of the longest longitudinal studies of depression, this effort also began the process when the participants were young, thus enabling the researchers to observe potential risks as the offspring of depressed parents transitioned from adolescence to adulthood.

Compared with a control group also followed for 30 years, the offspring of depressed parents had about three times the risk of developing depression as well, typically manifesting between the ages of 15 and 25. The offspring of parents with depression also had a greater risk of depression recurrence later in life, and displayed poorer functioning overall and increased chance of death from unnatural causes such as accidents or suicide.

Rush noted that not only are these results interesting from an academic standpoint, but also they demonstrate the value of regularly offering depression screening to patients.

“Clinicians who treat adults with major depression—especially if there are other affected family members or if the course is recurrent—could be of great service by offering a screening visit from time to time, or pediatricians could include a depression screen in the ‘annual checkup’ visit,” he wrote. “Had we a patient with a history of parental death from a myocardial infarction at age 36 or breast cancer at age 34, or familial melanoma, would we not screen these offspring earlier and more often? A change in psychiatric, pediatric, and school health practices is overdue.” ■