Black-and-white ideas don’t fit well in psychiatry, but they sometimes seep into my work nonetheless. There they nestle into some corner of uncertainty, making things a little more comfortable than they ought to be. In this issue, I expunge a few of them, with a little help from our friends.

Take genetic testing. People often ask the all-or-nothing question, “Is it useful or not?” That’s a bit like asking, “Is laboratory testing useful?” As John Nurnberger shows us, the answer depends on the test and the patient.

Then there’s long-term antidepressant therapy. Nassir Ghaemi has argued that a great fallacy of modern psychiatry is our belief that what is good for the short term must be good for the long term. With antidepressants in recurrent depression, this idea has become dogma, but Giovanni Fava describes an alternative view in this issue. He argues that antidepressants do their best work in the acute phase of the illness and ought to be followed by something with more lasting power, like psychotherapy, which may even replace them.

Next, Stephen Wyatt revives an old drug that some of us had put out to pasture—disulfiram. I had actually taken it off my electronic prescription list at one point, thinking it was too dangerous. But two things changed my mind. Alcohol-related problems rose to one of the top causes of death in the US, and disulfiram revealed itself to hold a larger effect size than other medications for alcohol use disorders in a few meta-analyses. Disulfiram isn’t right for everyone, but it’s not the deadly poison it’s sometimes made out to be.

Finally, we learn that light therapy is not just for seasonal depression, and open medical notes may not be such a bad thing, and may even do some good. Or is that “finally”? Read on, and maybe you’ll find a few sacred cows of your own to put out to pasture.

Chris Aiken, MD
caiken@thecarlatreport.com