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This Viewpoint discusses the benefits of rethinking the history of psychiatric epidemiology from a global perspective.

No metric more strongly illustrates global health than the vast series of numbers gathered in the Global Burden of Disease (GBD), a massive health data collection enterprise currently run and made available by the Institute for Health Metrics and Evaluation (IHME) at the University of Seattle with the financial support of the Gates Foundation. This system for assessing the impact of disease encompasses quite different numbers than those circulating in public health circles, such as epidemiological results or clinical trials outcomes. Looking at the trajectory of the GBD through reports, archives, interviews with actors from the World Bank, the WHO, networks centered on particular health conditions, or national and sub-national health administrations, this chapter tells a story about the economic turn in world health and the health turn in the economics of development. This story contrasts two periods. The first one covers the construction of this metric through a combination of health data and an external economic calculus involved in the World Bank’s “health turn,” a shift from massive infrastructural development projects to human capital investments like health and education in the 1990s. The chapter then examines the disjunction between how the GBD was conceptualized, with a strong focus on the comparative evaluation of cost-effectiveness, and how it was actually applied in global health policy. After some dormancy, the GBD reappeared, from the mid-2000s, as an enterprise of the university-affiliated IHME Institute on Health Metrics and Evaluation (IHME). In the hands of think tanks, consulting firms, governments, NGOs, academics, and the WHO, the GBD has moved from development economics to the health arenas of low- and middle-income countries (LMIC). Through this journey it has lost its edge as determining tool in health policies with the consequence that global health priorities worldwide and comparative burden data are barely related. GBD today has become a shared language whose numbers are reworked at the national level, used in isolation, as indicators of emergency, as developments in mental health or medical genetics show.

Resume Cet article analyse le remplacement de l’accompagnant familial en psychiatrie senegalaise par l’accompagnant remunere (dit « mercenaire »), en l’inscrivant dans la perspective constructiviste de la division sociale du travail hospitalier. Cette mutation est mise en relation avec les changements therapeutiques et economiques touchant l’hopital ainsi que la famille. Une ethnographie sur deux sites hospitaliers a permis d’analyser l’inscription du mercenaire en tant que travailleur subalterne dans le processus de gestion du malade psychiatrique. La place du mercenaire reste interstitielle au sein de l’organisation formelle. Lui sont deleguees des fonctions de securite et de care, centrales dans la psychiatrie au Senegal, tout en gardant une place ambigue dans l’organisation, par son caractere informel.

This chapter assesses Franco Basaglia’s enduring influence in France by focusing on the circulation of concepts and practices and their effects on French mental health policies and scattered experimentation. Despite similar origins, Basaglia’s early work contrasts with the Second World War movement of French psychiatric reformers to humanize the asylum, including through ‘psychothérapie institutionnelle’ and the subsequent development of a sectorization policy. The chapter then examines the extent to which Basaglia’s ideas took ground in France through the efforts of a small network of psychiatric practitioners and intellectuals, within roughly three periods: 1960–1980, 1980–2000, and 2000 to the present. In conclusion, the chapter asks what might explain the French paradox: the early receptivity to Basaglia’s politically-oriented, community-based, anti-institutional practice, on the one hand; and a tenacious hospital-centric psychiatric system and increased use of constraints and high-security confinement, on the other.

Reliable, clinically useful, and globally applicable diagnostic classification of mental disorders is an essential foundation for global mental health. The World Health Organization (WHO) is nearing completion of the 11th revision of the International Classification of Diseases and Related Health Problems (ICD‐11). The present study assessed inter‐diagnostician reliability of mental disorders accounting for the greatest proportion of global disease burden and the highest levels of service utilization – schizophrenia and other primary psychotic disorders, mood disorders, anxiety and fear‐related disorders, and disorders specifically associated with stress – among adult patients presenting for treatment at 28 participating centers in 13 countries. A concurrent joint‐rater design was used, focusing specifically on whether two clinicians, relying on the same clinical information, agreed on the diagnosis when separately applying the ICD‐11 diagnostic guidelines. A total of 1,806 patients were assessed by 339 clinicians in the local language. Intraclass kappa coefficients for diagnoses weighted by site and study prevalence ranged from 0.45 (dysthymic disorder) to 0.88 (social anxiety disorder) and would be considered moderate to almost perfect for all diagnoses. Overall, the reliability of the ICD‐11 diagnostic guidelines was superior to that previously reported for equivalent ICD‐10 guidelines. These data provide support for the suitability of the ICD‐11 diagnostic guidelines for implementation at a global level. The findings will inform further revision of the ICD‐11 diagnostic guidelines prior to their publication and the development of programs to support professional training and implementation of the ICD‐11 by WHO member states.

Within the proliferation of studies identified with global mental health, anthropologists rarely take global mental health itself as their object of inquiry. The papers in this special issue were selected specifically to problematize global mental health. To contextualize them, this introduction critically weighs three possible genealogies through which the emergence of global health can be explored: (1) as a divergent thread in the qualitative turn of global health away from earlier international health and development; (2) as the product of networks and social movements; and (3) as a diagnostically- and metrics-driven psychiatric imperialism, reinforced by pharmaceutical markets. Each paper tackles a different component of the assemblage of global mental health: knowledge production and circulation, global mental health principles enacted in situ, and subaltern modalities of healing through which global mental health can be questioned. Pluralizing anthropology, the articles include research sites in meeting rooms, universities, research laboratories, clinics, healers and health screening camps, households, and the public spaces of everyday life, in India, Ghana, Brazil, Senegal, South Africa, Kosovo and Palestine, as well as in US and European institutions that constitute nodes in the global network through which scientific knowledge and certain models of mental health circulate.

Following approval of the ICD‐11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD‐10 to the ICD‐11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders following ICD‐11’s approval. The development of the ICD‐11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD‐11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture‐related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery‐based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD‐11 classification of mental disorders as compared to the ICD‐10, and the development of two new ICD‐11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD‐11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD‐11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD‐11 and in preparing for implementation in their own professional contexts.

International audience; Peri-urban Senegal lies outside the influence of both the nation’s historic public mental health model and contemporary global mental health. This paper examines how cultural logics in this underserved region spill over from social domains to widen the therapeutic sphere of psychoses and epilepsy. Observations and 60 carer and/or patient interviews concerning 36 patients afflicted by one or both conditions illustrate how the “crisis of the uncanny”, a spectacular eruption of psychoses and seizures into the everyday, triggers trajectories across these domains. To resolve the crisis, patients and carers mobilize debts and obligations of extended kin and community, as well as a gift economy among strangers. The therapeutic and non-therapeutic are further linked through the semantics of falling, which associates this local term for the crisis with divine ecstasy and the slide from human to non-human forms of life. We introduce the concept of thick therapeutics to capture how the logics of sheep- other animal-human relationality, secular-divine politics of giving, and payment/sacrifice for healing imbue a therapeutic assemblage continually constructed through actions of patients, carers and healers. We ask what implications therapeutic thickening might have for mental health futures, such as monetized payment under global mental health.

We argue that predictions of a ‘tsunami’ of mental health problems as a consequence of the pandemic of coronavirus disease 2019 (COVID-19) and the lockdown are overstated; feelings of anxiety and sadness are entirely normal reactions to difficult circumstances, not symptoms of poor mental health. Some people will need specialised mental health support, especially those already leading tough lives; we need immediate reversal of years of underfunding of community mental health services. However, the disproportionate effects of COVID-19 on the most disadvantaged, especially BAME people placed at risk by their social and economic conditions, were entirely predictable. Mental health is best ensured by urgently rebuilding the social and economic supports stripped away over the last decade. Governments must pump funds into local authorities to rebuild community services, peer support, mutual aid and local community and voluntary sector organisations. Health care organisations must tackle racism and discrimination to ensure genuine equal access to universal health care. Government must replace highly conditional benefit systems by something like a universal basic income. All economic and social policies must be subjected to a legally binding mental health audit. This may sound unfeasibly expensive, but the social and economic costs, not to mention the costs in personal and community suffering, though often invisible, are far greater.

Dans le Senegal peri-urbain, les configurations du care informel se nouant autour du trouble mental chronique n’echappent pas au poids des crises economiques globales et de leurs effets sur la protection sociale et le soin en sante mentale. L’analyse fine du quotidien revele le travail emotionnel, physique et psychique du care qu’entraine la reponse aux besoins et a l’accompagnement therapeutique du malade. Si la precarisation croissante reduit les capacites des familles a fournir ce care sur le long terme, les formes de relations propres a l’environnement peri-urbain permettent l’emergence d’un phenomene nouveau : la figure du « non-apparente » venant completer, voire suppleer, le care porte par la famille.

International audience

Le processus de revision de la CIM-10 est dans sa phase finale. Apres une rapide comparaison historique des developpements des deux principales classifications diagnostiques des troubles, nous presenterons trois exemples de resultats des groupes de travail de l’OMS pour la revision. La participation des experts francophones, professionnels, usagers ou aidants (famille...) a ete tres faible jusqu’a present. L’OMS et les CCOMS francophones ainsi que le ministere belge de la Sante ont lance un projet commun pour promouvoir le developpement de la CIM-11 en francophonie dont le premier objectif est de recruter des participants francophones au Reseau mondial OMS de pratique clinique.

As part of the development of the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization Department of Mental Health and Substance Abuse is conducting a series of case-controlled field studies using a new and powerful method to test the application by clinicians of the proposed ICD-11 diagnostic guidelines for mental and behavioural disorders. This article describes the case-controlled field study for Disorders Specifically Associated with Stress. Using a vignette-based experimental methodology, 1,738 international mental health professionals diagnosed standardized cases designed to test key differences between the proposed diagnostic guidelines for ICD-11 and corresponding guidelines for ICD-10. Across eight comparisons, several proposed changes for ICD-11, including the addition of Complex PTSD and Prolonged Grief Disorder, produced significantly improved diagnostic decisions and clearer application of diagnostic guidelines compared to ICD-10. However, several key areas were also identified, such as the description of the diagnostic requirement of re-experiencing in PTSD, in which the guidelines were not consistently applied as intended. These results informed specific revisions to improve the clarity of the proposed ICD-11 diagnostic guidelines. The next step will be to further test these guidelines in clinic-based studies using real patients in relevant settings.Como parte del desarrollo de la onceava versión de la Clasificación Internacional de Enfermedades y Problemas de Salud Relacionados (CIE-11), la Organización Mundial de la Salud está conduciendo una serie de estudios de campo de casos controlados utilizando un novedoso y potente método para evaluar la aplicación por parte de clínicos de las guías diagnósticas para los trastornos mentales y del comportamiento. Este artículo describe el estudio de campo de casos controlados para los Trastornos específicamente relacionados con el estrés. Con base en una metodología experimental de viñetas, 1.738 profesionales de la salud mental diagnosticaron casos estandarizados específicamente diseñados para evaluar diferencias clave entre las guías propuestas para la CIE-11 y las que les corresponden en la CIE-10. Diversos cambios propuestos para la CIE-11, incluyendo la adición del TEPT complejo y del Trastorno por duelo prolongado, produjeron mejores decisiones diagnósticas en comparación con la versión previa del manual. Sin embargo, se identificaron también áreas en las que las guías no se aplicaron de manera consistente, como el requisito diagnóstico de re-experimentación para el TEPT, lo que informó revisiones específicas para mejorar las guías diagnósticas, que serán evaluadas en futuros estudios basados en la clínica con pacientes reales en escenarios relevantes.

This paper traces the early 21st century success of the agonist-antagonist buprenorphine and the combination drug buprenorphine with naloxone within the broader quest to develop addiction therapeutics that began in the 1920s as the search for a nonaddictive analgesic. Drawing on archival research, document analysis, and interviews with contemporary actors, this paper situates the social organization of laboratory-based and clinical research within the domestic and international confluence of several issues, including research ethics, drug regulation, public attitudes, tensions around definitions of drug addiction, and the evolving roles of the pharmaceutical industry. The fervor that drove the champions of buprenorphine must be understood in relation to (1) the material work of research and pharmaceutical manufacturing; (2) the symbolic role of buprenorphine as a solution to numerous problems with addiction treatment evident by the mid-1970s; the destigmatization and individualization of addicts as patients; and (3) the complex configurations of public and private partnerships.

In Louisiana's unique, populist-derived charity health system, the self-designation Charity Hospital Baby expresses situational identity anchored in the life cycle and the inversion of racist and authoritative connotations. This article draws on theoretical perspectives of stratified reproduction and the politics of time to examine the controversy in which Babies advocate reopening the Katrina-damaged New Orleans Charity Hospital, and administrators and planners support a new state-of-the-art biosciences district, GNOBED. Babies evoke the present, ethical urgency (kairos) of responding to sickness and disability; GNOBED implies prolonging or saving future lives through biotechnologies under development in accelerated time (chronos). As preservationists and residents threatened with displacement join “re-open Charity” proponents, planners symbolically engage in prolepsis, rhetorically precluding opposing arguments with flash forward of supposedly “done deals.” At stake is nothing less than social death for a segment of this ethnically diverse city.

Anne M. Lovell, PhD, is a member of the WHO International Advisory Group for the Revision of ICD-10 Mental and Behavioral Disorders. The views expressed in this commentary are her own and do not represent the views or policies of the World Health Organization or the Advisory Group. Address correspondence to Anne M. Lovell, Ph.D., CERMES 3 – Equipe CESAMES, INSERM 988, Universite de Paris Descartes, 45 rue des Saints-Peres, 75270 Paris Cedex 06, France. E-mail : anne.lovell@univ-paris5.fr. How can patient-subjective data improve clinical utility? Lovell

Article disponible sur le site de la revue http://www.cairn.info/revue-francaise-des-affaires-sociales-2009-1.htm#fiche; National audience; In France, despite the mobilisation of health consumer organizations, people with severe mental disorders (PSMD) have yet to consolidate shared knowledge of their condition. Rather than employ the still unstable official definitions of "psychic handicap", a notion akin but not equivalent to psychiatric disability, this article shows how through verbal exchanges, subjects can produce elements of a uniquely patient-based knowledge about the lived effects of their illness and its interaction with context and everyday life. Using perspectivist principles and modified conversation analysis, we conducted and analyzed collective interviews with members of both Mutual Aid Groups (MAG) and hospitalised patients. This allowed us to capture major aspects of shared consumer experiences, as both source and effect of disability. For these subjects, the invisible quality of psychic handicap becomes an obstacle to re-entering the realm of the "normal". Finally, the effects of treatment, of relationships and of administrative management, constitute, according to the interviewees, a double, or substitute "handicap", like the iatrogenic disability caused by medication effects. Patient knowledge thus clarifies how official recognition of the category the psychic handicap runs the risk of reproducing the very phenomena it aimed to diminish, namely stigmatisation and marginalisation.; En France, malgré le mouvement des associations de malades, les personnes ayant des troubles mentaux graves n'ont pas encore consolidé un savoir partagé de leur condition. Cet article se démarque des définitions officielles, bien qu'encore instables, du handicap psychique, afin de montrer que l'échange d'expériences de ces personnes peut néanmoins produire les éléments d'un savoir ordinaire, que l'on qualifie de " patientique ", et qui recouvre des situations où l'interaction de la maladie et du contexte et de la vie quotidienne se ressent. Des entretiens collectifs avec des membres de Groupes d'entraide mutuelle (GEM) et des patients hospitalisés nous ont permis de relever - grâce aux principes perspectivistes et d'analyse de conversation modifiée - des aspects centraux de l'expérience partagée de ces usagers, à la fois effets et sources de handicap. Ils font émerger par ailleurs la qualité invisible du handicap psychique comme obstacle au retour vers le monde des " normaux ". Enfin, les effets dérivés des soins, des relations, et des prises en charge administratives, rapportés par les interviewés, constituent une sorte de double, ou handicap de substitution, comme le " handicap iatrogène " lié à la médication. Le savoir patientique aide ainsi à identifier le risque de reproduire ce contre quoi la reconnaissance du handicap psychique a été mise en place, à savoir la stigmatisation et la marginalisation.

International audience; BACKGROUND: General practitioners (GPs) play a key role in identifying and managing patients with suicidal tendencies. Few studies, however, examine both GP and patient characteristics and GP practices associated with suicide assessment. This article aims to evaluate 1) GPs' success in early identification of suicidal ideation (SI) in patients starting antidepressant or anxiolytic treatment, and 2) patient- and GP-related factors associated with this success. METHODS: Survey of 144 GPs practising in southeastern France and of consecutive adults consulting them during June-October 2004 and prescribed antidepressant or anxiolytic treatment. Data were collected from GPs (consultation-questionnaires focusing on their prescription, diagnosis and detection of SI) and patients (self-administered questionnaires including the Hospital Anxiety and Depression scale and social and demographic characteristics). We used multilevel logistic regression to analyse factors associated with SI detection. RESULTS: GPs completed consultation-questionnaires for 713 patients, 405 of whom completed self-administered questionnaires. Eighty-nine patients (22%) reported SI; in 43 cases (48%) SI had not been detected by the GP. GPs detected SI more frequently when they had completed continuing medical education about depression, when patients had higher depressive symptom scores, and when consultations were relatively long. LIMITATIONS: Study limited to patients receiving initial prescriptions for antidepressants or anxiolytics. CONCLUSIONS: The percentage of undetected SI in this study population was high. Additional training of GPs increases the chances of detecting SI. Medical training and continuing medical education should include better instruction about SI risk factors and diagnosis, including non-major depressions, and stress that screening requires sufficient consultation time.

International audience

‘‘Psychiatry with teeth’’: with just three words, a head psychiatrist in Lyon, France, captures the confined spaces and internal discipline of a new type of intensive treatment center for ‘‘difficult patients’’ (Velpry and Eyraud 2014). His pithy phrase provides a vivid yet disconcerting image for the ‘rough edge’ of psychiatry where, as the editors of this issue of Culture, Medicine, and Psychiatry devoted to emergent forms of care and control remind us, constraint and coercion signal a fundamental division between patients and clinicians (Velpry and Brodwin 2014). At the level of institutions and the state, it is through constraint that the larger social ‘‘will’’ (to power, to social order) shows its teeth. We can understand ‘‘teeth’’ at the material level as the community supervision, restraints, locked units, quiet rooms, involuntary hospitalizations, and (in some cases) medications through which the will of clinicians and the power of institutions are enacted upon the bodies of psychiatrically defined individuals. Each of these papers offers a close reading of some aspect of this enactment at the local level. In the relationships constitutive of psychiatric practice, constraint and coercion mark the sites of greatest conflict between patient, clinician, and institution—the places where teeth are most likely to be bared in disputes over the moral status of the patient and the legitimacy of the institution. ‘Teething pains’ afflict those involved in this dynamic, pains of growth as individual clinicians learn to accept constraint as a necessary aspect of their work.

International audience; No abstract available

This study examined English- and Spanish-speaking psychologists' and psychiatrists' opinions regarding problematic, absent and stigmatizing diagnoses in current mental disorders classifications (ICD-10 and DSM-IV), and their perceived need for a national classification of mental disorders. Answers to open-ended questions included in WHO-WPA and WHO-IUPsyS surveys were examined using an inductive content-analysis method. A total of 3,222 participants from 35 countries were included. The most problematic diagnostic group was personality disorders, especially among psychiatrists, because of poor validity and lack of specificity. Complex posttraumatic stress disorder was the most frequent diagnosis suggested for inclusion, mainly by psychologists, to better account for the distinct processes and consequences of complex trauma. Schizophrenia was the diagnosis most frequently identified as stigmatizing, particularly by psychiatrists, due to lack of public understanding or knowledge about the diagnosis. Of the 14.4% of participants who perceived a need for a national classification system, two-thirds were from Africa or Latin America. The rationales provided were that mental disorders classifications should consider cultural and socio-historical diversity in the expression of psychopathology, differences in the perception of what is and is not pathological in different nations, and the existence of culture-bound syndromes. Implications for ICD-11 development and dissemination are discussed. © 2014 Asociación Española de Psicología Conductual.

International audience; This paper focuses on the relatively late emergence of psychiatric epidemiology as an international discipline, through local-global exchanges during the first 15 years of the World Health Organization (WHO). Building an epidemiological canon within WHO’s Mental Health Programme faced numerous obstacles. First, an idealist notion of mental health inherent in WHO’s own definition of health contributed to tensions around the object of psychiatric epidemiology. Second, the transfer of methods from medical epidemiology to research on mental disorders required mobilizing conceptual justifications, including a ‘contagion argument’. Third, epidemiological research at WHO was stymied by other public health needs, resource scarcity and cultural barriers. This history partly recapitulates the development of psychiatric epidemiology in North America and Europe, but is also shaped by concerns in the developing world, translated through first-world ‘experts’. Resolving the tensions arising from these obstacles allowed WHO to establish its international schizophrenia research, which in turn provided proof of concept for psychiatric epidemiology in the place of scepticism within and without psychiatry.

OBJECTIVES: This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS: Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS: Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS: With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Objective: To describe social and emotional problems in children and adolescents with neurofibromatosis type 1 (NF1) and propose interventions. Our hypothesis is that children with NF1 will have significantly more social and emotional problems, compared with their unaffected siblings and children in the general population. Study design: Forty-three children with NF1 and 22 unaffected siblings (ages 5 to 18 years) were assessed with a standardized test completed by parents and teachers (the Child Behavior Checklist). Results: As with other aspects of NF1, there was variable expressivity. However, when rated by parents, children with NF1 had significantly more problems in comparison with test norms or unaffected siblings on 7 of 8 scales: Social Problems, Attention Problems, Anxiety/Depression, Withdrawal, Thought Problems, Somatic Complaints, and Aggressive Behavior. Children with NF1 also scored lower than unaffected siblings on measures assessing sports and other activities. Teachers reported fewer differences. Conclusions: We propose interventions in the form of information for parents; early screening and treatment for speech, motor, and cognitive problems; and an increased level of intervention to prevent and treat psychologic problems, including systematic screening with standardized tests. (J Pediatr 1999;134:767-72)

Ask the Expert provides research-based answers to practice questions submitted by JSPN readers. Where possible, evidence from research is used to support the experts' recommendations.

In the United States, those street-dwelling homeless persons who suffer from serious psychiatric disabilities often reject the dependency generated by treatment modalities. Psychiatric and/or psychosocial rehabilitation, which emphasizes client choice, resonates with recent empowerment perspectives in community psychology, consumer-run mental health alternatives, and nontraditional homelessness programs. However, few of these approaches have been analyzed. This article examines critically how client choice, as a driving principle and idiographic concept, was constructed in a program for street-dwelling homeless persons labeled mentally ill by service providers. The cultural underpinnings of individualist choice are traced. This article analyzes the paradoxes of applying an idiographic framework, which favors case-by-case approaches over universally applicable rules, in a larger context of normatively oriented service organizations upon which the program depended for desired resources. Finally, it demonstr...

Thoracic tumors have been infrequently reported as a complication of neurofibromatosis-1 (NF1). To determine the prevalence and clinical features of thoracic tumors seen in children with NF1, we reviewed medical records and imaging studies for a group of 260 pediatric patients with NF1 followed in a multidisciplinary NF Center. Extrapleural thoracic tumors were seen in nine patients with NF1, corresponding to a prevalence of 3.5% in this hospital-based series of patients. Pathological studies of the tumors demonstrated plexiform neurofibroma in four cases and neurofibrosarcoma in one case. The remaining four cases were suspected to be plexiform neurofibroma based on clinical features but have not been confirmed histologically. Three patients presented with symptoms of chest pain, syncope, or wheezing; six patients were asymptomatic at the time of diagnosis of the tumors. Physical findings frequently found in patients with thoracic tumors were scoliosis (especially focal scoliosis) and visible plexiform neurofibromas of the neck. We conclude that NF1 patients presenting with any of these signs and symptoms should be screened for thoracic tumors with chest X-ray and magnetic resonance imaging as needed. It is unknown whether screening asymptomatic NF1 patients with chest X-rays on a regular basis will result in an improved outcome.

Recent narrative analysis in medical anthropology provides keys to both the personal meaning of illness and the historical, cultural, and institutional shaping of that experience. Yet Western psychiatric thinking and practice continue to view schizophrenic discourse as closed to interpretation. Caught in this "closed text," the self would seem obliterated. But using narratives of schizophrenia and homelessness, this essay proposes a different understanding of schizophrenic alterity. The openness of the text-as-experience is re-created collectively, from outside the subject's narration: the subject's "self is construction through the added perspectives of his or her interlocutors in the role of storymakers.

This paper traces the early 21st century success of the agonist-antagonist buprenorphine and the combination drug buprenorphine with naloxone within the broader quest to develop addiction therapeutics that began in the 1920s as the search for a nonaddictive analgesic. Drawing on archival research, document analysis, and interviews with contemporary actors, this paper situates the social organization of laboratory-based and clinical research within the domestic and international confluence of several issues, including research ethics, drug regulation, public attitudes, tensions around definitions of drug addiction, and the evolving roles of the pharmaceutical industry. The fervor that drove the champions of buprenorphine must be understood in relation to (1) the material work of research and pharmaceutical manufacturing; (2) the symbolic role of buprenorphine as a solution to numerous problems with addiction treatment evident by the mid-1970s; the destigmatization and individualization of addicts as patients; and (3) the complex configurations of public and private partnerships.