Author: douglasbergerpsychiatristtokyoblog

Douglas Berger, Tokyo Psychiatrist comments on, “The Best and Not so Great Articles of 2017.”

Original article:

 By Jerald Kay. MD. December 2017 issue of the Psychiatric Times.

A few points regarding the articles presented:

1.    On the Roy-Berne et al. article on “highlighting the myth of precision psychiatry”. I think Dr Kay and others need to have a long-term perspective. While genetic testing is a science in the embryo stage, it is not completely a myth. See this incredible study below. We need to be patient as this kind of science moves forward in the next 100-200 years-but it is not myth.

A population-based study of KCNH7 p.Arg394His and bipolar spectrum disorder. Hum Mol Genet. 2014 Dec 1; 23(23): 6395–6406. Strauss, et al.

From the abstract:

“We conducted blinded psychiatric assessments of 26 Amish subjects (52 ± 11 years) from four families with prevalent bipolar spectrum disorder, identified 10 potentially pathogenic alleles by exome sequencing, tested association of these alleles with clinical diagnoses in the larger Amish Study of Major Affective Disorder (ASMAD) cohort, and studied mutant potassium channels in neurons. Fourteen of 26 Amish had bipolar spectrum disorder. The only candidate allele shared among them was rs78247304, a non-synonymous variant of KCNH7 (c.1181G>A, p.Arg394His). KCNH7 c.1181G>A and nine other potentially pathogenic variants were subsequently tested within the ASMAD cohort, which consisted of 340 subjects grouped into controls subjects and affected subjects from overlapping clinical categories (bipolar 1 disorder, bipolar spectrum disorder and any major affective disorder). KCNH7 c.1181G>A had the highest enrichment among individuals with bipolar spectrum disorder (χ2 = 7.3) and the strongest family-based association with bipolar 1 (P = 0.021), bipolar spectrum (P = 0.031) and any major affective disorder (P = 0.016). Although our genome-wide statistical results do not alone prove association, cumulative evidence from multiple independent sources (parallel genome-wide study cohorts, pharmacological studies of HERG-type potassium channels, electrophysiological data) implicates neuronal HERG3/Kv11.3 potassium channels in the pathophysiology of bipolar spectrum disorder.”

  1.  On the Leichsenring F, et al. article on comparing CBT with psychodynamic therapy.

Any head-to-head comparisons are necessarily unblinded, neither patients nor therapists can be blind, there is no blind-placebo comparator either, and there is no way to filter out patient preference or treater bias. All the study endpoints are subjective and there is no way to robustly and logically compare these modalities as there is some improvement seen in every group that has some expectation and hope and receives a helping hand. Conclusion: these studies are a non-inferiority examination of subjective parameters of a human condition leading to no possible scientific conclusion.

  1.  On the Fonagy et al. paper, there is no proof that Relational theory is better or worse than CBT or neuroscience in describing psychopathology. This paper is clearly opinion and conjecture, and should be stated to be so.
  2.  On the Cabitza et al. paper questioning machine learning for medical care. Perhaps this is true in psychiatry, but for a field like oncology, it is clearly better to have a machine on your team:

Watson will see you now: a supercomputer to help clinicians make informed treatment decisions. Doyle-Lindrud S., Clin J Oncol Nurs. 2015 Feb;19(1):31-2.

“IBM has collaborated with several cancer care providers to develop and train the IBM supercomputer Watson to help clinicians make informed treatment decisions. When a patient is seen in clinic, the oncologist can input all of the clinical information into the computer system. Watson will then review all of the data and recommend treatment options based on the latest evidence and guidelines. Once the oncologist makes the treatment decision, this information can be sent directly to the insurance company for approval. Watson has the ability to standardize care and accelerate the approval process, a benefit to the healthcare provider and the patient”.

Doug Berger MD, Ph.D.

US Board-Certified Psychiatrist

Tokyo, Japan

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Doug Berger psychiatrist in Tokyo Comments on: “Innovative Strategies for Addressing Substance Use Disorders: The Classic Hallucinogens”

Original Article: Innovative Strategies for Addressing Substance Use Disorders: The Classic Hallucinogens

By Michael P. Bogenschutz, Psychiatric Times, April 20, 2017,

Dr. Bogenshultz describes this study: Residential psychedelic (LSD) therapy for the narcotic addict. Savage C, McCabe OL. A controlled study. Arch Gen Psychiatry. 1973 Jun;28(6):808-14.

Bogenshultz is taking the value of the results too far without looking at the design of this trial: Unblinded LSD drug given to persons who agree to be in the study. Low N of 39 persons in each comparator group.

He states it was a controlled trial of LSD-assisted treatment of heroin addiction, N=78 with heroin addiction randomized to abstinence based group therapy and urine monitoring vs. 4-5 wks of residential treatment , including a single high-dose LSD session, followed up usual care. Results showed that an “impressive” 25% in the LSD group were continuously abstinent during the 12 months follow up compared to 5% in the control group. 10/39 were abstinent in the LSD arm, and 2/39 abstinent in the control group.

Looking at it the other way, 29 persons (75%) who, in spite of AGREEING to and KNEW they were in the LSD group were not abstinent, and we don’t know how long abstinence lasted after the study ended. The LSD group is clearly not blind and these persons could have some strong placebo effect bias of hope and expectation of being in the active LSD group, and those in the control group knew they did not get LSD, in spite of having some interest in getting it because they knew it was an LSD study when they signed up for it, thus they may have had some disappointment. The researchers were also not-blind-you cant have one time high-dose LSD session and not know what is going on. The non-abstinent rates of 95% of controls and 75% in the active groups do not seem not all that different in the face of an unblinded treatment.

So here, in relatively low numbers studied, we have a fairly large percent of persons NOT maintaining abstinence despite being in an open LSD study. This was a methodologically troubled study: open label for LSD group, persons having an expectation if receiving LSD in both groups with a modest 20% more abstainers in the open LSD group. Open label drug and filtering out of patients who agree to get open label drug is not a controlled study.

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Douglas Berger, Psychiatrist in Tokyo Comments on, “Burden, Belonging, and Capability: An Interpersonal View of Military”. “Psychiatric Times”, March 28, 2017, By Nathaniel Brown, MD

I was surprised that Brown did not cite this article from “JAMA Psychiatry” May, 2014 that could have helped him understand something about half (or more) of servicemen: Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army. Results From the Army Study to Assess Risk and Resilience in Service members (Army STARRS)

The study found that almost half of soldiers had some mental disorder when they enlisted. The rates of disorders like attention deficit-hyperactivity disorder and intermittent explosive disorder (IED) in the study were similar in the new recruits as well.

This finding in line with our practice experience in Japan that includes servicing a total population of 100,000 military personnel, dependents, and civilian workers. Most of these persons seemed to us to have similar problems before they entered the service, some got worse in the service.

There is a clear path of employment, training, and for long-termers a pension plan, making the military both a good choice for these persons, and these persons a good choice for the military that recruiting is not likely to give up. However, ADD, ADHD, IED, etc are frequently associated with dysphoric mood states and recurrent brief, persistent, or major depression, in addition to drinking, drug abuse, risk taking behavior, and, along with the stresses of being in a war theater the risk of suicide can increase.

The answer to all of this is that, because so many persons enter the military with mental health problems to begin with, any addition of the horror of war to this baseline will continue to make it very challenging to mitigate morbidity and mortality in this population.

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Comment by Douglas Berger Psychiatrist in Japan on: Weighing the Benefits of Genetic Information in Clinical Psychiatry, Psychiatric Times, July 17, 2017 By Rebecca M. Allen, MD, MPH

The open-label GeneSight and unblined Genomind studies are at high-risk for researcher bias and should be suspect to extreme caution. We would never allow anti-depressants to be approved with these kinds of studies (although unblinded/no-blindplacebo psychotherapy studies are unreasonably and widely “accepted” as robust data by our profession all the time).

The issue of whether “adverse effects” are related to anxiety are easily investigated with zero-cost means. Patients’ significant others can manage all the medications, crush up the pills, and blind to the patient put them in patients’ morning small glass of orange juice. Do this a few days on and a few days off, keep a record, and see which days corresponded to the patient’s anxiety.

Regardless of a patient being a slow metabolizer, all patients should be started at low doses and can be told to break their starting dose pills in half, crush them, or empty capsules out so that every patient can start low and go slow for a number of days before going up to the low starting dose even. In addition, normal metabolizers may still have adverse effects at usual starting doses due to pharmacodynamics reasons (effects on the receptors etc in the brain) and not pharmacokinetic reasons (ie peripheral metabolism) which is not measured by metabolic genetic testing.

Proper clinical instruction and close follow up (which is necessary regardless of metabolic status) makes the use of these costly tests unnecessary in all but the rare patient with treatment resistance and/or those that have extreme reactions-only when drug is put in their OJ. I strongly suggest we never do a genetic test on any patient having “adverse reactions” on OJ with no drug in it and all the pills accounted for.
No genetic testing company is likely to be happy with what this advice may do to their market.

Doug Berger, MD, PhD
U.S. Board-Certified Psychiatrist
Tokyo, Japan

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RE: Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy

Psychiatric Times, April 03, 2017,  By Ronald W. Pies, MD

We all know about the slippery slope of giving psychiatric patients to right to request suicide from a medical professional. However, terminally ill medical patients who have terrible pain and suffering and are near death (perhaps on a respirator, have multi organ failure, frequent sepsis, oozing blood from skin and other orifices, repeated seizures, etc), are vastly different from psychiatric patients. Pies and Geppert’s argument does not deny that a physician could not induce a comatose state in these persons, perhaps even a permanent coma until death. Coma (without brain death) is not death medically or legally, although it essentially accomplishes the same thing as death does in removing the patient’s awareness and experience from a living state.

I would have trouble thinking that physician-assisted coma should be illegal or unethical as a form of medical treatment with specific indications just like any other medical treatment (i.e., it would not be indicated for psychiatric illness), and encourage further debate about it. One could argue that these patients can still be aware of things, but the same could be said of patients on morphine. Coma still racks up medical bills, and it may still be painful for a family to see their loved one in this state. Notwithstanding these caveats, we don’t have to argue about physician-assisted dying if we consider coma is good enough.

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