On the Origins of MAOI Misconceptions: Reaffirming their Role in Melancholic Depression.

The first monoamine oxidase inhibitors (MAOIs) used for the treatment of depression in the 1950-60s were credited with treating severe melancholic depression (MeD) successfully and greatly reducing the need for electroconvulsive therapy (ECT). Following the hiatus caused by the then ill-understood cheese reaction, MAOI use was relegated to atypical and treatment-resistant depressions only, based on data from insufficiently probing research studies suggesting their comparatively lesser effectiveness in MeD. The siren attraction of new 'better' drugs with different mechanisms amplified this trend. Following a re-evaluation of the data, we suggest that MAOIs are effective in MeD. Additionally, the broad unitary conceptualisation of major depressive disorder (MDD) in the DSM model diminished the chance of demonstrating distinctive responses to different antidepressant drugs (ADs) such as SSRIs, TCAs, and MAOIs, thereby further reducing the interest in MAOIs. More reliable categorical distinction of MeD, disentangling it from MDD, may be possible if more sensitive measuring instruments (CORE, SMPI) are used. We suggest these issues will benefit from re-appraisement via an inductive reasoning process within a binary (rather than a unitary) model for defining the different depressive disorders, allowing for the use of more reliable diagnostic criteria for MeD in particular. We conclude that MAOIs remain essential for, inter alia, TCA-resistant MeD, and should typically be used prior to ECT; additionally, they have a role in maintaining remission in cases treated with ECT (and ketamine/esketamine). We suggest that MAOIs should be utilized earlier in treatment algorithms and with greater regularity than is presently the case.

Paratonia, Gegenhalten and psychomotor hypertonia Back to the roots.

In the first half of the 20th century, well before the antipsychotic era, paratonia, Gegenhalten and psychomotor hypertonia were described as new forms of hypertonia intrinsic to particular psychoses and catatonic disorders. A series of astute clinical observations and experiments supported their independence from rigidity seen in Parkinson's disease. After World War II, motor disorders went out of fashion in psychiatry, with drug-induced parkinsonism becoming the prevailing explanation for all involuntary resistance to passive motion. With the 'forgetting' of paratonia and Gegenhalten, parkinsonism became the prevailing reading grid, such that the rediscovery of hypertonia in antipsychotic-naive patients at the turn of the 21st century is currently referred to as "spontaneous parkinsonism", implicitly suggesting intrinsic and drug-induced forms to be the same. Classical descriptive psychopathology gives a more nuanced view in suggesting two non-parkinsonian hypertonias: (i) locomotor hypertonia corresponds to Ernest Dupré's paratonia and Karl Kleist's reactive Gegenhalten; it is a dys-relaxation phenomenon that often needs to be activated. (ii) Psychomotor hypertonia is experienced as an admixture of assistance and resistance that partially overlaps with Kleist's spontaneous Gegenhalten, but was convincingly isolated by Henri Claude and Henri Baruk thanks to electromyogram recordings; psychomotor hypertonia is underpinned by "anticipatory contractions" of cortical origin, occurrence of which in phase or antiphase with the movement accounted for facilitation or opposition to passive motions. This century-old knowledge is not only of historical interest. Some results have recently been replicated in dementia and as now known to involve specific premotor systems.

The first psychiatric pandemic: Encephalitis lethargica, 1917-27.

Finding a link between COVID-19 and subsequent psychiatric symptoms has resulted in renewed interest in the psychiatric sequelae of pandemics. The first such instance was apparently the encephalitis lethargica pandemic which arose around the time of the First World War, moving in the shadow of a repiratory virus pandemic. The epidemic of encephalitis lethargica (EL), or Von Economo's Disease, in the years 1917-27 was the first pandemic involving the central nervous system. It moved in some places in parallel with the Great Flu Pandemic but does not seem to have been caused by it. Unlike the coronavirus, pandemic EL affected children heavily, leading often to bizarre changes in character and personality. It often left sequelae lasting for decades in the form of postencephalitic Parkinsonism (PEP). Unlike the coronavirus, it had a high mortality of around 20 percent. Although encephalitis lethargica involved a number of systems, psychiatric morbidity was most prominent and entailed severe depression, mania, catatonia and psychosis. It ended without therapeutic or public-health measures; today, sporadic cases of EL continue to be reported. The hypothesis is that we can derive from the EL psychiatric pandemic certain lessons that might be useful in studying tardive COVID symptoms today.

How amytal changed psychopharmacy: off-label uses of sodium amytal (1920-40).

In the early 1930s, American neurologist and psychiatrist William Bleckwenn used sodium amytal to render catatonic patients responsive, so that he could engage in talk therapy. Bleckwenn found a new, 'off-label' use for this anaesthetic and anxiolytic medication in psychiatry and, in doing so, allowed for important discoveries in the diagnosis and treatment of catatonia. Pharmacological textbooks reveal a 'label', while the Index-Catalogue of the Library of the Surgeon-General's Office reveals explorations 'off label' of barbiturates. The 'off-label' use of barbiturates facilitated talk therapy, heralding an important shift in psychopharmacy. Drugs previously only used as chemical restraints became a form of treatment for specific psychiatric diseases. The current strictures against off-label prescribing are overprescriptive and close off innovative new uses.

Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key.

PURPOSE OF REVIEW: Self-injurious behaviour (SIB) is a devastating condition frequently encountered in autism spectrum disorders (ASDs) that can lead to dangerous tissue injury and profound psychosocial difficulty. An increasing number of reports over the past decade have demonstrated the swift and well tolerated resolution of intractable SIB with electroconvulsive therapy (ECT) when psychopharmacological and behavioural interventions are ineffective. The current article provides a review of the salient literature, including the conceptualization of repetitive self-injury along the catatonia spectrum, and further clarifies the critical distinction between ECT and contingent electric shock. RECENT FINDINGS: We searched electronically for literature regarding ECT for self-injurious behaviour from 1982 to present, as the first known report was published in 1982. Eleven reports were identified that presented ECT in the resolution of self-injury in autistic or intellectually disabled patients, and another five reports discussed such in typically developing individuals. These reports and related literature present such self-injury along the spectrum of agitated catatonia, with subsequent implications for ECT. SUMMARY: Intractable self-injury remains a significant challenge in ASDs, especially when patients do not respond adequately to behavioural and psychopharmacological interventions. ECT is well tolerated and efficacious treatment for catatonia, and can confer marked reduction in SIB along the agitated catatonia spectrum.

The history of nosology and the rise of the Diagnostic and Statistical Manual of Mental Disorders.

The current Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 arose from a tradition filled with haphazard science and politically driven choices. The nosology of modern psychiatry began with the German classifiers of the late 19th century, especially Emil Kraepelin. Psychoanalysis then blotted out the classificatory vision for the next half-century, and most of this European psychopathological science failed to cross the Atlantic. The DSM series was a homegrown American product, beginning with Medical 203 in 1945, then guided by psychoanalytic insights through DSM-I in 1952 and DSM-II in 1968. In 1980, DSM-III represented a massive "turning of the page" in nosology, and it had the effect of steering psychoanalysis toward the exit in psychiatry and the beginning of a reconciliation of psychiatry with the rest of medicine. With the advent of DSM-5, however, questions are starting to be asked about whether this massive venture is on the right track.

El actual DSM-5 (Manual Diagnóstico y Estadístico) surgió de una tradición llena de ciencia casual y opciones impulsadas políticamente. La nosología de la moderna psiquiatría comenzó con los clasificadores alemanes de finales del siglo XIX, en especial Emil Kraepelin. Posteriormente el psicoanálisis empañó la visión clasificatoria por el siguiente medio siglo, y la mayor parte de esta ciencia psicopatológica europea no logró cruzar el Atlántico. La serie de los DSM es un producto americano hecho en casa, que comenzó con Medical 203 en 1945, y luego fue orientado por concepciones psicoanalíticas a través del DSM-I en 1952 y el DSM-II en 1968. En 1980 el DSM-III representó una masiva "vuelta de página" en la nosología, encauzó el psicoanálisis hacia la salida de la psiquiatría y comenzó con la reconciliación de la psiquiatría con el resto de la medicina. Sin embargo; con la aparición del DSM-5 están surgiendo preguntas para ser respondidas acerca de si esta gran iniciativa está por el camino correcto.

L'actuel DSM-5 (Manuel diagnostique et statistique) provient d'une tradition nourrie de science peu méthodique et de choix politiques. La nosologie de la psychiatrie moderne a commencé avec les classificateurs allemands du XIXe siècle, en particulier Emile Kraepelin. Pendant la première moitié du siècle suivant, la psychanalyse a ensuite effacé la vision classificatrice et la plupart de cette science psychopathologique européenne n'a pas réussi à traverser l'Atlantique. La série des DSM est un produit américain autochtone, commençant avec le Medical 203 en 1945, puis guidée par des points de vue psychanalytiques du DSM-I en 1952 au DSM-II en 1968. En 1980, le DSM-III a permis de « tourner la page ¼ complètement en nosologie, en ayant pour effet de guider la psychanalyse vers la sortie en psychiatrie et de débuter une réconciliation entre la psychiatrie et le reste de la médecine. Cependant, l'avènement du DSM-5 remet en question la pertinence de la voie de cette gigantesque entreprise.

The 25th anniversary of the launch of Prozac gives pause for thought: where did we go wrong?

The creation, in DSM-III, of the category 'major depression' can be linked to the launch, and success, of Prozac. The consequences of creating this broad diagnostic category are of concern in relation to the treatment of individuals with a diverse variety of depressive disorders.

Psychiatry and fads: why is this field different from all other fields?

Fads in psychiatry are little more than bad ideas with short half-lives. They have arisen because of the great discontinuities that have swept psychiatry unlike other specialties in the 20th century: the transition in the 1920s from asylum-based biological psychiatry to psychoanalysis, and the transition in the 1960s from psychoanalysis to a biological model based on psychopharmacology. In no other medical specialty has the knowledge base been scrapped and rebuilt, and then again scrapped and rebuilt. In these great transitions, when psychiatry each time has had to reconstruct from scratch, bad ideas have crept in with good. Psychiatry, in its heavy use of consensus conferences, is often unable to employ science as a means of discarding fads, which, once installed, are often difficult to remove. Each of the great paradigms of psychiatry in the last hundred years has given rise to fads, and psychopharmacology is no exception, with faddish uses of neurotransmitter doctrine claiming centre stage. Only when psychiatry becomes firmly linked to the neurosciences will its subjugation to the turbulence of faddism be moderated.

Les modes en psychiatrie ne sont guère plus que de mauvaises idées ayant de brèves demi-vies. Elles sont apparues en raison des grandes discontinuités qui ont balayé la psychiatrie comme nulle autre spécialité au 20e siècle : la transition dans les années 1920 de la psychiatrie biologique des asiles à la psychanalyse, et la transition dans les années 1960 de la psychanalyse à un modèle biologique fondé sur la psychopharmacologie. Aucune autre spécialité médicale n'a vu sa base de connaissances démolie et reconstruite, puis démolie et reconstruite encore. Dans ces grandes transitions, où chaque fois la psychiatrie a dû recommencer à neuf, de mauvaises idées se sont insinuées avec les bonnes. La psychiatrie, qui s'appuie lourdement sur les conférences consensuelles, est souvent incapable d'employer la science comme moyen d'éliminer les modes qui, une fois en place, sont souvent difficiles à écarter. Chacun des grands paradigmes de la psychiatrie des 100 dernières années a donné lieu à des modes, et la psychopharmacologie ne fait pas exception, avec sa mode d'utiliser la doctrine des neurotransmetteurs qui réclame le centre de la scène. Ce n'est que lorsque la psychiatrie deviendra fermement liée aux neurosciences qu'elle pourra calmer sa fascination pour la turbulence des modes passagères.