Reviews of Note

In an occasional column, NEJM Journal Watch Psychiatry editors comment briefly on review articles.

Two systems for fear and anxiety circuits. Advances in neuroscience have helped delineate fear- and anxiety-related circuits in the brain associated with many clinical anxiety disorders. Referring to “fear” as feelings that arise when a known threat of harm is immediate or imminent and to “anxiety” as feelings evoked by uncertain sources likely to cause harm in distal time or space, these authors critique earlier and simpler models of fear centers and related circuits.¹ They propose that distinguishing two distinct but overlapping circuits, with subcortical and cortical anatomic correlates, may help further both clinical understanding and, ultimately, treatment — a “defensive survival circuit” responding to sensory input with defensive physiological reactions and behavioral actions, and a “cognitive circuit” that supports conscious feeling states and appraisal of threats. The authors contend that unpacking these two systems will lead to better individualized treatment (e.g., targeting one or the other system depending on individual symptom profiles) and more discriminating research.

Postpartum psychosis. Covering the epidemiology of postpartum psychosis and its diagnostic and clinical features, etiology, treatment, prevention, and needs for further treatment, this review offers clear-cut guidelines for diagnostic workup and specific treatment recommendations.² The authors underscore considerations for safety planning for patients and infants, including urgent needs for inpatient care and the significant benefits of lithium and electroconvulsive therapy. Because relapse occurs in 31% of patients with isolated postpartum psychosis and because many patients manifest episodes after the postpartum period, usually of a bipolar-spectrum nature, diligent attention and ongoing monitoring are necessary.

Mental and substance use disorders: Treatment challenges. The authors of this health policy report³ comprehensively examine the major issues regarding mental and substance use disorders in U.S. healthcare today: They are highly prevalent and disabling, but infrequently and ineffectively treated. Barriers include continuing insurance limitations despite parity laws; a shrinking supply of psychiatrists, many of whom do not accept insurance; and poor access to care for disadvantaged populations who suffer disproportionately from these disorders. Separation of medical and mental health systems are being addressed with models of integrated care, which are being encouraged by the Affordable Care Act and by medical societies and some insurance companies. However, insurance limitations and continuing differences in the culture of medical and mental health systems and providers impose challenges. Actual legislation may be required to effect change but may be difficult in the current political environment. This essay is must reading for any psychiatrist interested in understanding the care-delivery landscape and its possible future.

Bipolar disorder in primary care practices. Although most primary care physicians are well acquainted with managing uncomplicated depression, they also encounter numerous other psychiatric disorders. These authors have conducted a meta-analysis of 16 studies (425,691 participants) to determine the prevalence of bipolar disorders in primary care practice.⁴ They estimate the prevalence of bipolar disorder in primary care to be 1.9% globally (pooled prevalence across 8 studies reporting only current diagnosis, 3.7%) and 3.7% in North America. (Based on other data from 226 practices across 43 U.S. states comparing the prevalence rates of 24 diseases [J Am Board Fam Med 2013; 26:518], this study's findings would result in ranking bipolar disorders as 14th in a list of common chronic conditions, just after chronic obstructive pulmonary disease [prevalence, 4.35%] and just before chronic kidney disease [prevalence, 3.37%]. Depression was rated third [prevalence, 18.67%].)

These findings suggest both that primary care physicians should become well acquainted with the management of bipolar disorders and that psychiatrists working in integrated-care settings can expect bipolar disorder to be a common reason for referral.

Migraines and psychiatric disorders: A complex relationship. The co-occurrence of migraine headaches and psychiatric disorders is common. Here, the authors comprehensively review the association, the etiologic connections, and treatment implications.⁵ They note a bidirectional effect: Migraine is more common in patients who have depression, anxiety, and bipolar disorder, and depression, anxiety, and bipolar disorder are more common in those who have migraines. Stress can be a trigger for migraine, but stress reduction is also associated with increased migraine risk. Post-traumatic stress disorder, but not trauma, increases migraine risk — an interesting observation that should be studied in individuals with mild traumatic brain injury and comorbid migraines. Psychiatric disorders are associated with migraine “chronification”; thus, recognition and treatment are important. This article is important for all clinicians.

Borderline personality disorder in the elderly. What happens with older patients with borderline personality disorder? These authors have reviewed studies involving patients over age 65 and longitudinal studies of patients over age 50.⁶ The reviewers suggest that as patients age, impulsive and identity disturbance diminish, but depression, emptiness, and somatic complaints worsen. Suicide attempts are less frequent but may become more lethal. Emotional dysregulation, intense anger, unstable relationships, and attachment insecurity persist, often affecting patients' health behaviors.

Basics of poststroke depression. Reviewing diagnosis, neurobiological mechanisms, prognosis, and treatment of poststroke depression, these authors report that clinically significant depression occurs in about 30% to 50% of patients after cerebrovascular accidents.⁷ Depression is strongly linked to stroke severity and is further associated with poststroke mortality, largely due to cardiovascular causes. Giving antidepressant medication to depressed poststroke patients, whether or not the patient was depressed prior to stroke, is associated with improved survival. This practice, recommended by the American Heart Association, should be continued for >6 months after recovery.