Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.14 Genetic Counseling

Other Issues Evidence suggests that therapy can induce physical changes in the nervous system. Eric Kandel has provided elegant proof, winning the Nobel Prize for demonstrating that environmen- tal stimuli produce lasting changes in the synaptic architecture of living organisms. Imaging studies have begun to show that patients who show clinical improvement from psychotherapy show changes in brain metabolism that are similar to that seen in patients successfully treated with medications. Still, some patients do well on only one form of treatment. Even with identical diagnoses, not all patients respond to the same treatment regimens. Success may be as dependent on the knowledge and quality of the clinician as on the potential ben- efit of a particular drug. A real dilemma when combining treatment is the additional direct costs of two treatments. Although successful treatment results in reduced costs to society, the cost of treatment is usu- ally narrowly defined by the patient as out-of-pocket expenses and by insurance and managed care companies as payments to the physician or hospital. Restrictions placed on the frequency and cost of visits to mental health professionals by managed care organizations, however, encourage the use of medication rather than psychotherapy. R eferences Anton RF, O’Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, Gast- friend DR, Hosking JD, Johnson BA, LoCastro JS, Longabaugh R, Mason BJ, Mattson ME, Miller WR, Pettinati HM, Randall CL, Swift R, Weiss RD, Williams LD, Zweben A. Combined pharmacotherapies and behavioral inter- ventions for alcohol dependence: The COMBINE study: A randomized con- trolled trial. JAMA. 2006;295:2003. Arean PA, Cook BL. Psychotherapy and combined psychotherapy/pharmacother- apy for late life depression. Biol Psychiatry. 2002;52:293–303. Beitman BD, Blinder BJ, Thase ME, Riba M, Safer DL. Integrating Psychotherapy and Pharmacotherapy: Dissolving the Mind-Brain Barrier. New York: Norton; 2003. Blais MA, Malone JC, Stein MB, Slavin-Mulford J, O’Keefe SM, Renna M, Sin- clair SJ. Treatment as usual (TAU) for depression: a comparison of psycho- therapy, pharmacotherapy, and combined treatment at a large academic medical center. Psychotherapy (Chic). 2013;50(1):110–118. Brent DA, Birmhaher B. Adolescent depression. N Engl J Med. 2002;347:667–671. Burnand Y, Andreoli A, Kolatte E, Venturini A, Rosset N. Psychodynamic psy- chotherapy and clomipramine in the treatment of major depression. Psychiatr Serv. 2002;53:585–590. Friedman MA, Detweiler-Bedell JB, Leventhal HE, Horne R, Keitner GI, Miller IW. Combination psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol. 2004;11:47–68. Karon BP. Effective Psychoanalytic Therapy of Schizophrenia and Other Severe Disorders. Washington, DC: American Psychological Association; 2002. Otto MW, Smits JAJ, Reese HE. Combination psychotherapy and pharmaco- therapy for mood and anxiety disorders in adults: Review and analysis. Clin Psychol. 2005;12:72–86. Overholser JC. Where has all the psyche gone? Searching for treatments that focus on psychological issues. J Contemp Psychother. 2003;33:49–61. Peeters F, Huibers M, Roelofs J, van Breukelen G, Hollon SD, Markowitz JC, van Os J, Arntz A. The clinical effectiveness of evidence-based interventions for depression: A pragmatic trial in routine practice. J Affect Disord. 2013; 145(3):349–355. Preskorn SH. Psychopharmacology and psychotherapy: What’s the connection? J Psychiatr Pract. 2006;12(1):41. RayWA, Daugherty JR, Meador KG. Effect of a mental health “carve-out”program on the continuity of antipsychotic therapy. N Engl J Med. 2003;348:1885–1894. Schmidt NB. Combining psychotherapy and pharmacological service provision for anxiety pathology. J Cogn Psychother. 2005;19(4):307. Szigethy, EM, Friedman, ES. Combined psychotherapy and pharmacology. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Text- book of Psychiatry. 9 th ed. Vol. 2. Philadelphia: Lippincott Williams &Wilkins; 2009:2923. Szuhany KL, Kredlow MA, Otto MW. Combination Psychological and Pharma- cological Treatments for Panic Disorder. Int J Cogn Ther . 2014;7(2):122–135. Ver Eecke W. In understanding and treating schizophrenia: A rejoinder to the PORT report’s condemnation of psychoanalysis. J AmAcad Psychanal. 2003;31:11–29.

▲▲ 28.14 Genetic Counseling Medical geneticists and specially trained and qualified genetic counselors have traditionally provided genetic counseling to patients in need of such help. Many psychiatrists, however, are also well placed to provide genetic education and counseling because they often have knowledge of their clients’ needs and family histories and have ongoing therapeutic relationships. The ideal approach for providing psychiatric genetic counseling is through a multidisciplinary team approach, with collaboration between genetics and mental health professionals. Genetic pro- fessionals often seek collaboration with a psychiatrist for those with difficult psychiatric medical or family histories. Genetic professionals also seek collaboration or referral for persons with a psychiatric disorder; those who are having difficulty adapt- ing to a genetic-related diagnosis; those dealing with the death of a family member; or those who are experiencing persistent difficulty with decision making regarding prenatal diagnosis or genetic testing. In turn, genetic professionals can be available for professional consultation regarding risk assessment, the collec- tion and construction of complicated family medical histories, and the availability and limitations of genetic or genomic testing. Definitions Genetic counseling is the process of helping people to under- stand and adapt to the medical, psychological, and familial implications of genetic contributions to disease. According to the National Society of Genetic Counseling, it integrates three factors: (1) interpretation of family and medical his- tories to assess the chance of disease occurrence or recur- rence; (2) education about inheritance, testing, management, prevention, resources, and research; and (3) counseling to promote informed choices and adaptation to the risk or con- dition. The process aims to minimize distress and facilitate adaptation, to increase one’s feeling of personal control, and to facilitate informed decision making and life planning. Genetic counseling is not limited to considerations of the genetic contributions of disease. Genetic counseling also con- siders environmental components of the presenting disease along with genetic ones. Table 28.14-1 lists common terminol- ogy used in the field of genetic counseling. Figure 28.14-1 illus- trates a complex family medical history presented in the form of a pedigree. Genetics and Mental Health Disorders can recur in families for many reasons, including the functioning of genes (single genes vs. polygenic) (Table 28.14-2), shared environmental exposures, a combination of genetic and environmental factors (multifactorial), and cultural transmis- sion. Single gene disorders are caused by defects in one particu- lar gene, and they often have simple and predictable inheritance patterns. By contrast, most psychiatric disorders are multifacto- rial in etiology, influenced by multiple genes as well as environ- mental factors, making them more difficult to predict. Two phenomena that further complicate genetic counseling include penetrance and expressivity. Penetrance refers to the portion of indi- viduals with a specific genotype who also manifest that genotype at the