Henry A. Nasrallah, MD

Depression treatment seems to be in a “funk” these days. Armchair critics, some of whom have never treated a depressed patient, are flooding the media and Internet with allegations that antidepressants—which have helped patients for decades—are no better than placebo.

Several major pharmaceutical companies have pared down or shut down their CNS discovery, research, and development operations. There is a lack of new antidepressants with novel mechanisms of action, and the proportion of refractory or treatment-resistant depression (TRD) seems to be growing. In short, the status of clinical depression seems rather depressing.

Yet nothing can be further from the truth! A vibrant set of innovative, even radical, solutions for TRD are on the horizon. Here are some of the paradigm shifts in the neurobiology and therapeutics of major depression that gradually are toppling decades-old tenets and creeds related to this serious psychiatric disorder:

From genes vs environment to gene × environment interaction. For decades, it was assumed that some people have “endogenous” depression due to genetic determinants, while others are afflicted with “exogenous” depression caused by stressful life events. The new model shows that the environment interacts with genes to produce depression, and that having only risk genes or only environmental stress does not necessarily lead to depression.¹

From ‘chemical imbalance’ to ‘inflammatory process.’ Evidence is accumulating that inflammation may be underpinning depression,² and studies show levels of inflammatory cytokines and interleukins rise during a depressive episode and decline when the depression remits.

From ‘neurotransmitters’ to ‘neuroplasticity and neurotropic factors.’ Current treatments were developed to increase neurotransmitter activity in the brain, but new research reveals that depression is associated with a significant drop in neurotropic factors such as brain derived neurotropic factor (BDNF) or fibroblast growth factor with a concomitant decline in hippocampal neurogenesis.³

From serotonin, norepinephrine, and dopamine to glutamate. Over the past few years, glutamate pathways and the glutamate N-methyl-D-aspartate (NMDA) receptor have emerged as possibly of central importance to the neurobiology of depression.⁴ The link between the strong therapeutic effects of antagonizing the NMDA receptor in depression and the increase in BDNF and neuroplasticity has emerged as a fresh model of depression.

From pills to intravenous infusions. Studies have shown that a single infusion of the NMDA receptor antagonist ketamine produces a very robust response, including full remission, in treatment–resistant unipolar or bipolar depression within 1 to 2 hours!⁵ The mechanism of action has been attributed to a surge of BDNF and immediate neuroplastic changes⁴ following NMDA receptor blockade. This abrupt reversal of severe depression, like turning on a switch, is a total and pleasant surprise.

From monotherapy to augmentation strategies. The rather imprudent notion that a single medication can be effective in a heterogeneous spectrum of disorders such as depression gradually is yielding to intelligent polypharmacy, using evidence-based augmentation strategies that might include lithium, thyroid hormone, another antidepressant (particularly mirtazapine), atypical antipsychotics, anti-inflammatory agents (including omega-3 fatty acids), antioxidants (especially N-acetylcysteine), L-methylfolate, and exercise.

From pharmacotherapy to neuromodulation. Because they disseminate to all organs and not just the brain, medications can cause undesirable side effects. Neuromodulation is used to treat depression by stimulating specific brain regions. Electroconvulsive therapy has a tarnished image but well established efficacy in severe depression. Repetitive transcranial magnetic stimulation and vagus nerve stimulation are FDA-approved for treating depression, while other forms of neuromodulation, such as cranial electrical stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, near infrared light therapy, and transcranial direct current stimulation, still are in development.⁶ Deep brain stimulation (DBS) has been shown in several recent studies to reverse TRD,^7,8 especially when stimulating the subgenual anterior cingulated region. In the future, DBS may become as commonly used in depression as it currently is in Parkinson’s disease.

A remarkable transformation is underway to reinvent the causes and treatments of depression that will reignite optimism about what psychiatry can do and eliminate the disability associated with major depression. Our patients can hardly wait.

Depression treatment seems to be in a “funk” these days. Armchair critics, some of whom have never treated a depressed patient, are flooding the media and Internet with allegations that antidepressants—which have helped patients for decades—are no better than placebo.

Several major pharmaceutical companies have pared down or shut down their CNS discovery, research, and development operations. There is a lack of new antidepressants with novel mechanisms of action, and the proportion of refractory or treatment-resistant depression (TRD) seems to be growing. In short, the status of clinical depression seems rather depressing.

Yet nothing can be further from the truth! A vibrant set of innovative, even radical, solutions for TRD are on the horizon. Here are some of the paradigm shifts in the neurobiology and therapeutics of major depression that gradually are toppling decades-old tenets and creeds related to this serious psychiatric disorder:

From genes vs environment to gene × environment interaction. For decades, it was assumed that some people have “endogenous” depression due to genetic determinants, while others are afflicted with “exogenous” depression caused by stressful life events. The new model shows that the environment interacts with genes to produce depression, and that having only risk genes or only environmental stress does not necessarily lead to depression.¹

From ‘chemical imbalance’ to ‘inflammatory process.’ Evidence is accumulating that inflammation may be underpinning depression,² and studies show levels of inflammatory cytokines and interleukins rise during a depressive episode and decline when the depression remits.

From ‘neurotransmitters’ to ‘neuroplasticity and neurotropic factors.’ Current treatments were developed to increase neurotransmitter activity in the brain, but new research reveals that depression is associated with a significant drop in neurotropic factors such as brain derived neurotropic factor (BDNF) or fibroblast growth factor with a concomitant decline in hippocampal neurogenesis.³

From serotonin, norepinephrine, and dopamine to glutamate. Over the past few years, glutamate pathways and the glutamate N-methyl-D-aspartate (NMDA) receptor have emerged as possibly of central importance to the neurobiology of depression.⁴ The link between the strong therapeutic effects of antagonizing the NMDA receptor in depression and the increase in BDNF and neuroplasticity has emerged as a fresh model of depression.

From pills to intravenous infusions. Studies have shown that a single infusion of the NMDA receptor antagonist ketamine produces a very robust response, including full remission, in treatment–resistant unipolar or bipolar depression within 1 to 2 hours!⁵ The mechanism of action has been attributed to a surge of BDNF and immediate neuroplastic changes⁴ following NMDA receptor blockade. This abrupt reversal of severe depression, like turning on a switch, is a total and pleasant surprise.

From monotherapy to augmentation strategies. The rather imprudent notion that a single medication can be effective in a heterogeneous spectrum of disorders such as depression gradually is yielding to intelligent polypharmacy, using evidence-based augmentation strategies that might include lithium, thyroid hormone, another antidepressant (particularly mirtazapine), atypical antipsychotics, anti-inflammatory agents (including omega-3 fatty acids), antioxidants (especially N-acetylcysteine), L-methylfolate, and exercise.

From pharmacotherapy to neuromodulation. Because they disseminate to all organs and not just the brain, medications can cause undesirable side effects. Neuromodulation is used to treat depression by stimulating specific brain regions. Electroconvulsive therapy has a tarnished image but well established efficacy in severe depression. Repetitive transcranial magnetic stimulation and vagus nerve stimulation are FDA-approved for treating depression, while other forms of neuromodulation, such as cranial electrical stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, near infrared light therapy, and transcranial direct current stimulation, still are in development.⁶ Deep brain stimulation (DBS) has been shown in several recent studies to reverse TRD,^7,8 especially when stimulating the subgenual anterior cingulated region. In the future, DBS may become as commonly used in depression as it currently is in Parkinson’s disease.

A remarkable transformation is underway to reinvent the causes and treatments of depression that will reignite optimism about what psychiatry can do and eliminate the disability associated with major depression. Our patients can hardly wait.

Depression treatment seems to be in a “funk” these days. Armchair critics, some of whom have never treated a depressed patient, are flooding the media and Internet with allegations that antidepressants—which have helped patients for decades—are no better than placebo.

Several major pharmaceutical companies have pared down or shut down their CNS discovery, research, and development operations. There is a lack of new antidepressants with novel mechanisms of action, and the proportion of refractory or treatment-resistant depression (TRD) seems to be growing. In short, the status of clinical depression seems rather depressing.

Yet nothing can be further from the truth! A vibrant set of innovative, even radical, solutions for TRD are on the horizon. Here are some of the paradigm shifts in the neurobiology and therapeutics of major depression that gradually are toppling decades-old tenets and creeds related to this serious psychiatric disorder:

From genes vs environment to gene × environment interaction. For decades, it was assumed that some people have “endogenous” depression due to genetic determinants, while others are afflicted with “exogenous” depression caused by stressful life events. The new model shows that the environment interacts with genes to produce depression, and that having only risk genes or only environmental stress does not necessarily lead to depression.¹

From ‘chemical imbalance’ to ‘inflammatory process.’ Evidence is accumulating that inflammation may be underpinning depression,² and studies show levels of inflammatory cytokines and interleukins rise during a depressive episode and decline when the depression remits.

From ‘neurotransmitters’ to ‘neuroplasticity and neurotropic factors.’ Current treatments were developed to increase neurotransmitter activity in the brain, but new research reveals that depression is associated with a significant drop in neurotropic factors such as brain derived neurotropic factor (BDNF) or fibroblast growth factor with a concomitant decline in hippocampal neurogenesis.³

From serotonin, norepinephrine, and dopamine to glutamate. Over the past few years, glutamate pathways and the glutamate N-methyl-D-aspartate (NMDA) receptor have emerged as possibly of central importance to the neurobiology of depression.⁴ The link between the strong therapeutic effects of antagonizing the NMDA receptor in depression and the increase in BDNF and neuroplasticity has emerged as a fresh model of depression.

From pills to intravenous infusions. Studies have shown that a single infusion of the NMDA receptor antagonist ketamine produces a very robust response, including full remission, in treatment–resistant unipolar or bipolar depression within 1 to 2 hours!⁵ The mechanism of action has been attributed to a surge of BDNF and immediate neuroplastic changes⁴ following NMDA receptor blockade. This abrupt reversal of severe depression, like turning on a switch, is a total and pleasant surprise.

From monotherapy to augmentation strategies. The rather imprudent notion that a single medication can be effective in a heterogeneous spectrum of disorders such as depression gradually is yielding to intelligent polypharmacy, using evidence-based augmentation strategies that might include lithium, thyroid hormone, another antidepressant (particularly mirtazapine), atypical antipsychotics, anti-inflammatory agents (including omega-3 fatty acids), antioxidants (especially N-acetylcysteine), L-methylfolate, and exercise.

From pharmacotherapy to neuromodulation. Because they disseminate to all organs and not just the brain, medications can cause undesirable side effects. Neuromodulation is used to treat depression by stimulating specific brain regions. Electroconvulsive therapy has a tarnished image but well established efficacy in severe depression. Repetitive transcranial magnetic stimulation and vagus nerve stimulation are FDA-approved for treating depression, while other forms of neuromodulation, such as cranial electrical stimulation, epidural cortical stimulation, focused ultrasound, low field magnetic stimulation, magnetic seizure therapy, near infrared light therapy, and transcranial direct current stimulation, still are in development.⁶ Deep brain stimulation (DBS) has been shown in several recent studies to reverse TRD,^7,8 especially when stimulating the subgenual anterior cingulated region. In the future, DBS may become as commonly used in depression as it currently is in Parkinson’s disease.

A remarkable transformation is underway to reinvent the causes and treatments of depression that will reignite optimism about what psychiatry can do and eliminate the disability associated with major depression. Our patients can hardly wait.

Neurocognitive impairment—especially of memory—has been documented in several major psychiatric disorders, including schizophrenia, bipolar mania, and major depressive disorder, and is linked to functional disability.

Psychiatric researchers are feverishly developing and testing medications to improve episodic, visuospatial, and working memory. A coalition of academic researchers, the pharmaceutical industry, the FDA, and the National Institute of Mental Health has collaborated to develop a standard cognitive battery for schizophrenia in a project called MATRICS—Measurement and Treatment Research to Improve Cognition in Schizophrenia. Controlled clinical trials currently are underway using various mechanisms of action, but no cognition-enhancing agent has been FDA-approved for schizo-phrenia or any other psychiatric disorder. Acetylcholinesterase inhibitors, approved for Alzheimer’s dementia, have not demonstrated efficacy in mental illness.

What can practitioners do to help their patients’ neurocognitive functions, especially memory? There are many causes for secondary memory deficits besides primary memory dysfunction, which is part of the neurobiology of severe psychiatric brain disorders. Therapeutic strategies to avoid or reverse secondary cognitive impairment can preserve patients’ cognitive reserve until evidence-based pharmacotherapies or somatic therapies such as neurostimulation are available. One or more of the following tactics may be useful:

Avoid anticholinergic medications. Anticholinergic agents can seriously impair memory. If a psychotic patient develops extrapyramidal symptoms, consider reducing the antipsychotic dose instead of adding benztropine. Avoid using older antidepressants or antipsychotics with strong anticholinergic effects.

Avoid long-term benzodiazepine use. Benzodiazepines impair memory and should be used only occasionally.

Help patients lose weight. Many psychiatric patients are overweight, and studies have linked a body mass index of ≥25 with memory decrement in the general population¹ and in persons with schizophrenia.² Helping patients change their lifestyle habits (diet and exercise) can not only reduce early cardiovascular mortality but also restore some memory capacity.

Prescribe regular exercise. In addition to improving cardiovascular fitness and helping reduce memory-impairing intra-abdominal fat, at the brain level regular exercise stimulates the production of progenitor cells in the hippocampus—the brain’s memory center—that can grow and mature into neurons and glia. There is no easier and safer way to sharpen memory than regular exercise. Brisk walking for 30 minutes or more every day will bring on cognitive benefits and slow brain aging.

Encourage stimulating activities. Birds placed in colorful, stimulating cages with a new décor every day develop brains that are 10% to 20% larger than birds placed in ordinary cages without environmental stimulation. The same principle applies to humans. Brain stimulation with crossword puzzles, chess, backgammon, puzzles, video games, or exposure to novel activities on a regular basis can help progenitor cells produced in the hippocampus mature into full-fledged neurons. Combining physical exercise to proliferate neurogenesis with mental exercise to grow and mature the newborn neurons is arguably the best formula for a sharper memory. ³

Avoid sedating medications. Somnolence and sedation caused by some psychotropic agents can slow cognitive processes and impair information processing and memory consolidation and retrieval.

Lower patients’ blood pressure. Studies have linked hypertension to memory decline.4 Treating hypertension can restore baseline memory.

Treat obstructive sleep apnea (OSA). Repeated cerebral ischemia caused by nocturnal apnea—which occurs in many obese patients—is associated with cognitive decline, adding insult to injury in patients with primary memory impairment, such as schizophrenia. Continuous positive airway pressure is a standard treatment for OSA and can help patients avoid serious drops in blood oxygen saturation caused by lack of normal breathing.

Recommend omega-3 fatty acid supplements. Although no direct relationship has been established between omega-3 fatty acids and memory enhancement, the potent anti-inflammatory effects of omega-3 fatty acids may reduce the detrimental effects of cerebral inflammation caused by pro-inflammatory factors produced in the periomental (visceral) adiposity in obese and highly obese individuals with big bellies.

Until definitive treatments become available for the primary memory deficits of patients with schizophrenia, bipolar disorder, or major depressive disorder, these interventions can help preserve and even grow the baseline “cognitive capital” of those patients. Above all, preventing psychotic, manic, or depressive relapses is of paramount importance because such episodes appear to have “neurotoxic” effects and are associated with atrophic brain changes. Nothing is more devastating to neurocognition than brain tissue loss and cortical atrophy. It would not be surprising if future memory-enhancing drugs will have strong neuroprotective properties that enhance neuroplasticity and neuroregeneration.

Neurocognitive impairment—especially of memory—has been documented in several major psychiatric disorders, including schizophrenia, bipolar mania, and major depressive disorder, and is linked to functional disability.

Psychiatric researchers are feverishly developing and testing medications to improve episodic, visuospatial, and working memory. A coalition of academic researchers, the pharmaceutical industry, the FDA, and the National Institute of Mental Health has collaborated to develop a standard cognitive battery for schizophrenia in a project called MATRICS—Measurement and Treatment Research to Improve Cognition in Schizophrenia. Controlled clinical trials currently are underway using various mechanisms of action, but no cognition-enhancing agent has been FDA-approved for schizo-phrenia or any other psychiatric disorder. Acetylcholinesterase inhibitors, approved for Alzheimer’s dementia, have not demonstrated efficacy in mental illness.

What can practitioners do to help their patients’ neurocognitive functions, especially memory? There are many causes for secondary memory deficits besides primary memory dysfunction, which is part of the neurobiology of severe psychiatric brain disorders. Therapeutic strategies to avoid or reverse secondary cognitive impairment can preserve patients’ cognitive reserve until evidence-based pharmacotherapies or somatic therapies such as neurostimulation are available. One or more of the following tactics may be useful:

Avoid anticholinergic medications. Anticholinergic agents can seriously impair memory. If a psychotic patient develops extrapyramidal symptoms, consider reducing the antipsychotic dose instead of adding benztropine. Avoid using older antidepressants or antipsychotics with strong anticholinergic effects.

Avoid long-term benzodiazepine use. Benzodiazepines impair memory and should be used only occasionally.

Help patients lose weight. Many psychiatric patients are overweight, and studies have linked a body mass index of ≥25 with memory decrement in the general population¹ and in persons with schizophrenia.² Helping patients change their lifestyle habits (diet and exercise) can not only reduce early cardiovascular mortality but also restore some memory capacity.

Prescribe regular exercise. In addition to improving cardiovascular fitness and helping reduce memory-impairing intra-abdominal fat, at the brain level regular exercise stimulates the production of progenitor cells in the hippocampus—the brain’s memory center—that can grow and mature into neurons and glia. There is no easier and safer way to sharpen memory than regular exercise. Brisk walking for 30 minutes or more every day will bring on cognitive benefits and slow brain aging.

Encourage stimulating activities. Birds placed in colorful, stimulating cages with a new décor every day develop brains that are 10% to 20% larger than birds placed in ordinary cages without environmental stimulation. The same principle applies to humans. Brain stimulation with crossword puzzles, chess, backgammon, puzzles, video games, or exposure to novel activities on a regular basis can help progenitor cells produced in the hippocampus mature into full-fledged neurons. Combining physical exercise to proliferate neurogenesis with mental exercise to grow and mature the newborn neurons is arguably the best formula for a sharper memory. ³

Avoid sedating medications. Somnolence and sedation caused by some psychotropic agents can slow cognitive processes and impair information processing and memory consolidation and retrieval.

Lower patients’ blood pressure. Studies have linked hypertension to memory decline.4 Treating hypertension can restore baseline memory.

Treat obstructive sleep apnea (OSA). Repeated cerebral ischemia caused by nocturnal apnea—which occurs in many obese patients—is associated with cognitive decline, adding insult to injury in patients with primary memory impairment, such as schizophrenia. Continuous positive airway pressure is a standard treatment for OSA and can help patients avoid serious drops in blood oxygen saturation caused by lack of normal breathing.

Recommend omega-3 fatty acid supplements. Although no direct relationship has been established between omega-3 fatty acids and memory enhancement, the potent anti-inflammatory effects of omega-3 fatty acids may reduce the detrimental effects of cerebral inflammation caused by pro-inflammatory factors produced in the periomental (visceral) adiposity in obese and highly obese individuals with big bellies.

Until definitive treatments become available for the primary memory deficits of patients with schizophrenia, bipolar disorder, or major depressive disorder, these interventions can help preserve and even grow the baseline “cognitive capital” of those patients. Above all, preventing psychotic, manic, or depressive relapses is of paramount importance because such episodes appear to have “neurotoxic” effects and are associated with atrophic brain changes. Nothing is more devastating to neurocognition than brain tissue loss and cortical atrophy. It would not be surprising if future memory-enhancing drugs will have strong neuroprotective properties that enhance neuroplasticity and neuroregeneration.

Neurocognitive impairment—especially of memory—has been documented in several major psychiatric disorders, including schizophrenia, bipolar mania, and major depressive disorder, and is linked to functional disability.

Psychiatric researchers are feverishly developing and testing medications to improve episodic, visuospatial, and working memory. A coalition of academic researchers, the pharmaceutical industry, the FDA, and the National Institute of Mental Health has collaborated to develop a standard cognitive battery for schizophrenia in a project called MATRICS—Measurement and Treatment Research to Improve Cognition in Schizophrenia. Controlled clinical trials currently are underway using various mechanisms of action, but no cognition-enhancing agent has been FDA-approved for schizo-phrenia or any other psychiatric disorder. Acetylcholinesterase inhibitors, approved for Alzheimer’s dementia, have not demonstrated efficacy in mental illness.

What can practitioners do to help their patients’ neurocognitive functions, especially memory? There are many causes for secondary memory deficits besides primary memory dysfunction, which is part of the neurobiology of severe psychiatric brain disorders. Therapeutic strategies to avoid or reverse secondary cognitive impairment can preserve patients’ cognitive reserve until evidence-based pharmacotherapies or somatic therapies such as neurostimulation are available. One or more of the following tactics may be useful:

Avoid anticholinergic medications. Anticholinergic agents can seriously impair memory. If a psychotic patient develops extrapyramidal symptoms, consider reducing the antipsychotic dose instead of adding benztropine. Avoid using older antidepressants or antipsychotics with strong anticholinergic effects.

Avoid long-term benzodiazepine use. Benzodiazepines impair memory and should be used only occasionally.

Help patients lose weight. Many psychiatric patients are overweight, and studies have linked a body mass index of ≥25 with memory decrement in the general population¹ and in persons with schizophrenia.² Helping patients change their lifestyle habits (diet and exercise) can not only reduce early cardiovascular mortality but also restore some memory capacity.

Prescribe regular exercise. In addition to improving cardiovascular fitness and helping reduce memory-impairing intra-abdominal fat, at the brain level regular exercise stimulates the production of progenitor cells in the hippocampus—the brain’s memory center—that can grow and mature into neurons and glia. There is no easier and safer way to sharpen memory than regular exercise. Brisk walking for 30 minutes or more every day will bring on cognitive benefits and slow brain aging.

Encourage stimulating activities. Birds placed in colorful, stimulating cages with a new décor every day develop brains that are 10% to 20% larger than birds placed in ordinary cages without environmental stimulation. The same principle applies to humans. Brain stimulation with crossword puzzles, chess, backgammon, puzzles, video games, or exposure to novel activities on a regular basis can help progenitor cells produced in the hippocampus mature into full-fledged neurons. Combining physical exercise to proliferate neurogenesis with mental exercise to grow and mature the newborn neurons is arguably the best formula for a sharper memory. ³

Avoid sedating medications. Somnolence and sedation caused by some psychotropic agents can slow cognitive processes and impair information processing and memory consolidation and retrieval.

Lower patients’ blood pressure. Studies have linked hypertension to memory decline.4 Treating hypertension can restore baseline memory.

Treat obstructive sleep apnea (OSA). Repeated cerebral ischemia caused by nocturnal apnea—which occurs in many obese patients—is associated with cognitive decline, adding insult to injury in patients with primary memory impairment, such as schizophrenia. Continuous positive airway pressure is a standard treatment for OSA and can help patients avoid serious drops in blood oxygen saturation caused by lack of normal breathing.

Recommend omega-3 fatty acid supplements. Although no direct relationship has been established between omega-3 fatty acids and memory enhancement, the potent anti-inflammatory effects of omega-3 fatty acids may reduce the detrimental effects of cerebral inflammation caused by pro-inflammatory factors produced in the periomental (visceral) adiposity in obese and highly obese individuals with big bellies.

Until definitive treatments become available for the primary memory deficits of patients with schizophrenia, bipolar disorder, or major depressive disorder, these interventions can help preserve and even grow the baseline “cognitive capital” of those patients. Above all, preventing psychotic, manic, or depressive relapses is of paramount importance because such episodes appear to have “neurotoxic” effects and are associated with atrophic brain changes. Nothing is more devastating to neurocognition than brain tissue loss and cortical atrophy. It would not be surprising if future memory-enhancing drugs will have strong neuroprotective properties that enhance neuroplasticity and neuroregeneration.

Psychiatry has many strengths, some weaknesses, and quite a few threats. Therefore, it is vital that psychiatry aggressively focuses on emerging opportunities and exploits them to reinvent its future.

To do that effectively, psychiatry must undergo a process of “creative destruction”¹ to shed its old baggage and tenets, and reinvent itself as a premier medical specialty anchored in evidence-based behavioral neuroscience.

For quite some time, psychiatrists have been patiently waiting for disruptive discoveries catalyzed by ongoing momentous advances and innovative technologies generated by discoveries in molecular genetics and neurobiology. However, psychiatry needs to embrace not only disruptive technologies but also “disruptive thinking” to help reengineer its structure and function and lead to a quantum leap toward a brilliant future anchored in cutting-edge neuroscience.

What facets of psychiatry could undergo creative destruction? What sacred cows should be sacrificed on the altar of necessary, creative change? Imagine the following scenarios:

Create a new name. The term “psychiatry” is based on the archaic concept of “the psyche” from an era of ignorance about the brain generating the mind. Psyche has outlived its usefulness and needs to be shed. A new name incorporating neural structures and functions must reflect the brain mechanisms that generate abnormal thought, mood, or cognition. In addition, the labels currently attached to psychiatric disorders also could also be changed, including stigmatizing diagnoses such as schizophrenia, mania, or borderline personality disorder. New names for such disorders can be linked to brain lesions, pathways, or circuits underlying them. Several years ago Japan replaced the term “schizophrenia” with “integration disorder,” which was met with a positive response from patients and practitioners.²

Destroy false mythology. Misconception and lore of what psychiatry is or is not continues to mislead and distort its scientific principles, goals, and procedures. Creative destruction will give rise to a scientific identity, transcending the absurd fables that shrouded psychiatry since its formative years.

Revolutionize diagnostic models. Current diagnostic schemes are obsolete and must be deconstructed and creatively reinvented based on scientific findings, not just a set of clinical signs and symptoms. The creative destruction process will draw upon scientific breakthroughs and pathophysiological findings psychiatric neuroscientists are discovering (almost daily!). Numerous lab data have been developed for psychiatric disorders, but extensive heterogeneity has prevented diagnostic or commercial use of those tests because of sensitivity/specificity variability.

Design novel treatment approaches. Innovations are desperately needed to create new therapeutics for psychiatric brain disorders. Several dogmas must be slain (such as “chemical imbalance”) and replaced with modern “brain repair” processes, including neuroplasticity and neuroprotection. This would accelerate novel brain interventions such as neuromodulation (eg, repetitive transcranial magnetic simulation, vagus nerve stimulation, and deep brain stimulation) and may set the stage for gene-based therapies, including epigenetic silencing of genes associated with specific disorders. Psychotherapy must be reframed as “verbal neurotherapy” because it certainly leads to salutary neuroplastic changes. As for pharmacologic agents, a new paradigm translating neurobiologic discoveries into effective “neurobiotherapies” must become the pharmaceutical industry’s new focus; a paradigm shift to different delivery systems (intravenous, intranasal, intrathecal, etc.) that can rapidly switch off hallucinations, anxiety attacks, depression, or suicidal urges. Examples of this already exist.³

Transform the delivery system setting. The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into “brain institutes,” in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated.

New specialization and training model. The psychiatrist of the future ideally will be double boarded in neurology and psychiatry, function more like behavioral neurologists, and provide psychotherapy as needed. A full, accurate assessment of the “mind” cannot be accomplished without a complete assessment of the brain because the mind essentially is the virtual brain. Assessment and management of schizophrenia, depression, or obsessive-compulsive disorder should be no less rigorous neurologically than that of stroke, multiple sclerosis, or Parkinson’s disease.

New image. Psychiatry’s new identity must project a distinctly scientific new image as a superb and highly regarded medical discipline. Creative destruction would involve a difficult transition for “grandfathered” psychiatrists, who will have to abandon old habits and attitudes and retool to adopt new skills. Embracing radical change can be challenging, but we can count on psychiatrists’ abilities and their resilience in adapting to change to when it occurs.

A new destiny. Just as the stunning metamorphosis from embryo to larva, pupa, and imago precedes the emergence of a magnificent butterfly, psychiatry must shatter its cocoon and emerge into a new reality and destiny. Creative destruction is the means for renewal. It is scary to some and exciting to others, but imperative for all.

Psychiatry has many strengths, some weaknesses, and quite a few threats. Therefore, it is vital that psychiatry aggressively focuses on emerging opportunities and exploits them to reinvent its future.

To do that effectively, psychiatry must undergo a process of “creative destruction”¹ to shed its old baggage and tenets, and reinvent itself as a premier medical specialty anchored in evidence-based behavioral neuroscience.

For quite some time, psychiatrists have been patiently waiting for disruptive discoveries catalyzed by ongoing momentous advances and innovative technologies generated by discoveries in molecular genetics and neurobiology. However, psychiatry needs to embrace not only disruptive technologies but also “disruptive thinking” to help reengineer its structure and function and lead to a quantum leap toward a brilliant future anchored in cutting-edge neuroscience.

What facets of psychiatry could undergo creative destruction? What sacred cows should be sacrificed on the altar of necessary, creative change? Imagine the following scenarios:

Create a new name. The term “psychiatry” is based on the archaic concept of “the psyche” from an era of ignorance about the brain generating the mind. Psyche has outlived its usefulness and needs to be shed. A new name incorporating neural structures and functions must reflect the brain mechanisms that generate abnormal thought, mood, or cognition. In addition, the labels currently attached to psychiatric disorders also could also be changed, including stigmatizing diagnoses such as schizophrenia, mania, or borderline personality disorder. New names for such disorders can be linked to brain lesions, pathways, or circuits underlying them. Several years ago Japan replaced the term “schizophrenia” with “integration disorder,” which was met with a positive response from patients and practitioners.²

Destroy false mythology. Misconception and lore of what psychiatry is or is not continues to mislead and distort its scientific principles, goals, and procedures. Creative destruction will give rise to a scientific identity, transcending the absurd fables that shrouded psychiatry since its formative years.

Revolutionize diagnostic models. Current diagnostic schemes are obsolete and must be deconstructed and creatively reinvented based on scientific findings, not just a set of clinical signs and symptoms. The creative destruction process will draw upon scientific breakthroughs and pathophysiological findings psychiatric neuroscientists are discovering (almost daily!). Numerous lab data have been developed for psychiatric disorders, but extensive heterogeneity has prevented diagnostic or commercial use of those tests because of sensitivity/specificity variability.

Design novel treatment approaches. Innovations are desperately needed to create new therapeutics for psychiatric brain disorders. Several dogmas must be slain (such as “chemical imbalance”) and replaced with modern “brain repair” processes, including neuroplasticity and neuroprotection. This would accelerate novel brain interventions such as neuromodulation (eg, repetitive transcranial magnetic simulation, vagus nerve stimulation, and deep brain stimulation) and may set the stage for gene-based therapies, including epigenetic silencing of genes associated with specific disorders. Psychotherapy must be reframed as “verbal neurotherapy” because it certainly leads to salutary neuroplastic changes. As for pharmacologic agents, a new paradigm translating neurobiologic discoveries into effective “neurobiotherapies” must become the pharmaceutical industry’s new focus; a paradigm shift to different delivery systems (intravenous, intranasal, intrathecal, etc.) that can rapidly switch off hallucinations, anxiety attacks, depression, or suicidal urges. Examples of this already exist.³

Transform the delivery system setting. The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into “brain institutes,” in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated.

New specialization and training model. The psychiatrist of the future ideally will be double boarded in neurology and psychiatry, function more like behavioral neurologists, and provide psychotherapy as needed. A full, accurate assessment of the “mind” cannot be accomplished without a complete assessment of the brain because the mind essentially is the virtual brain. Assessment and management of schizophrenia, depression, or obsessive-compulsive disorder should be no less rigorous neurologically than that of stroke, multiple sclerosis, or Parkinson’s disease.

New image. Psychiatry’s new identity must project a distinctly scientific new image as a superb and highly regarded medical discipline. Creative destruction would involve a difficult transition for “grandfathered” psychiatrists, who will have to abandon old habits and attitudes and retool to adopt new skills. Embracing radical change can be challenging, but we can count on psychiatrists’ abilities and their resilience in adapting to change to when it occurs.

A new destiny. Just as the stunning metamorphosis from embryo to larva, pupa, and imago precedes the emergence of a magnificent butterfly, psychiatry must shatter its cocoon and emerge into a new reality and destiny. Creative destruction is the means for renewal. It is scary to some and exciting to others, but imperative for all.

Psychiatry has many strengths, some weaknesses, and quite a few threats. Therefore, it is vital that psychiatry aggressively focuses on emerging opportunities and exploits them to reinvent its future.

To do that effectively, psychiatry must undergo a process of “creative destruction”¹ to shed its old baggage and tenets, and reinvent itself as a premier medical specialty anchored in evidence-based behavioral neuroscience.

For quite some time, psychiatrists have been patiently waiting for disruptive discoveries catalyzed by ongoing momentous advances and innovative technologies generated by discoveries in molecular genetics and neurobiology. However, psychiatry needs to embrace not only disruptive technologies but also “disruptive thinking” to help reengineer its structure and function and lead to a quantum leap toward a brilliant future anchored in cutting-edge neuroscience.

What facets of psychiatry could undergo creative destruction? What sacred cows should be sacrificed on the altar of necessary, creative change? Imagine the following scenarios:

Create a new name. The term “psychiatry” is based on the archaic concept of “the psyche” from an era of ignorance about the brain generating the mind. Psyche has outlived its usefulness and needs to be shed. A new name incorporating neural structures and functions must reflect the brain mechanisms that generate abnormal thought, mood, or cognition. In addition, the labels currently attached to psychiatric disorders also could also be changed, including stigmatizing diagnoses such as schizophrenia, mania, or borderline personality disorder. New names for such disorders can be linked to brain lesions, pathways, or circuits underlying them. Several years ago Japan replaced the term “schizophrenia” with “integration disorder,” which was met with a positive response from patients and practitioners.²

Destroy false mythology. Misconception and lore of what psychiatry is or is not continues to mislead and distort its scientific principles, goals, and procedures. Creative destruction will give rise to a scientific identity, transcending the absurd fables that shrouded psychiatry since its formative years.

Revolutionize diagnostic models. Current diagnostic schemes are obsolete and must be deconstructed and creatively reinvented based on scientific findings, not just a set of clinical signs and symptoms. The creative destruction process will draw upon scientific breakthroughs and pathophysiological findings psychiatric neuroscientists are discovering (almost daily!). Numerous lab data have been developed for psychiatric disorders, but extensive heterogeneity has prevented diagnostic or commercial use of those tests because of sensitivity/specificity variability.

Design novel treatment approaches. Innovations are desperately needed to create new therapeutics for psychiatric brain disorders. Several dogmas must be slain (such as “chemical imbalance”) and replaced with modern “brain repair” processes, including neuroplasticity and neuroprotection. This would accelerate novel brain interventions such as neuromodulation (eg, repetitive transcranial magnetic simulation, vagus nerve stimulation, and deep brain stimulation) and may set the stage for gene-based therapies, including epigenetic silencing of genes associated with specific disorders. Psychotherapy must be reframed as “verbal neurotherapy” because it certainly leads to salutary neuroplastic changes. As for pharmacologic agents, a new paradigm translating neurobiologic discoveries into effective “neurobiotherapies” must become the pharmaceutical industry’s new focus; a paradigm shift to different delivery systems (intravenous, intranasal, intrathecal, etc.) that can rapidly switch off hallucinations, anxiety attacks, depression, or suicidal urges. Examples of this already exist.³

Transform the delivery system setting. The disastrously dysfunctional public mental health bureaucracy must be abandoned and transformed into “brain institutes,” in all states, similar to cancer centers or cardiovascular institutes, where state-of-the-art clinical care, training, and research are integrated.

New specialization and training model. The psychiatrist of the future ideally will be double boarded in neurology and psychiatry, function more like behavioral neurologists, and provide psychotherapy as needed. A full, accurate assessment of the “mind” cannot be accomplished without a complete assessment of the brain because the mind essentially is the virtual brain. Assessment and management of schizophrenia, depression, or obsessive-compulsive disorder should be no less rigorous neurologically than that of stroke, multiple sclerosis, or Parkinson’s disease.

New image. Psychiatry’s new identity must project a distinctly scientific new image as a superb and highly regarded medical discipline. Creative destruction would involve a difficult transition for “grandfathered” psychiatrists, who will have to abandon old habits and attitudes and retool to adopt new skills. Embracing radical change can be challenging, but we can count on psychiatrists’ abilities and their resilience in adapting to change to when it occurs.

A new destiny. Just as the stunning metamorphosis from embryo to larva, pupa, and imago precedes the emergence of a magnificent butterfly, psychiatry must shatter its cocoon and emerge into a new reality and destiny. Creative destruction is the means for renewal. It is scary to some and exciting to others, but imperative for all.

Psychiatrists often have to deal with “ethically challenged” entities or individuals. This can be of concern because, ultimately, unethical policies or behavior can harm our patients. However, psychiatrists recognize that what may appear to be unethical to them may not be considered as such by nonpsychiatrists.

Ethics (from Ethos, which means customs) is defined as the standards and rules of conduct that govern a set of human actions by a specific group, profession, or culture. Thus, there are medical ethics, corporate ethics, Christian ethics, student ethics, fishing ethics, etc. Ethics is, therefore, not an absolute standard and may exist only “in the eye of the beholder.” For example, psychiatry as a medical specialty has its own rigorous ethical code that other medical specialties do not uphold (such as prohibiting socializing with patients).

Who are the entities whose ethical transgressions may affect psychiatrists’ work? Consider the following examples:

Insurance companies. Some of their business practices outrage psychiatrists, including:

• vehemently opposing parity for psychiatric brain disorders with other medical disorders
• refusing to cover preexisting conditions
• the preauthorization farce, which costs psychiatrists a large amount of uncompensated time and effort (essentially an unfunded mandate)
• low reimbursement rate for psychiatric care and a bias against coverage for psychotherapy
• forcing stable patients to switch to a cheaper medication that may not work as well, thus potentially destabilizing the patient.

Pharmaceutical companies. Because of intense scrutiny by regulatory and compliance bodies, pharmaceutical companies have largely discontinued questionable practices such as:

• not publishing unfavorable drug data
• minimizing serious side effects such as obesity and diabetes until after their drug is widely used.

However, some companies continue to disconcert psychiatrists and trigger their umbrage by:

• abandoning psychiatric drug development despite the tremendous unmet need and shifting resources to more profitable therapeutic areas
• direct-to-consumer advertising that disrupts the doctor-patient relationship and undermines psychiatrists’ clinical judgment.

The FDA. This key government agency plays an important role in protecting the public, but its policies occasionally spawn ethical dilemmas.

For example, why does it insist that new psychiatric medications be indicated for a DSM “diagnosis” instead of common “symptoms” such as agitation, depression, delusions, hallucinations, anxiety, or impulsivity? DSM diagnoses are arbitrary, committee-created constructs that may change drastically from edition to edition. There is extensive evidence for overlapping symptoms of many psychiatric “diagnoses,” which implies that a drug approved and deemed safe and effective for 1 psychiatric syndrome (eg, psychosis, depression) can help other disorders that share symptoms.

Why doesn’t the FDA channel the billions of dollars in penalties they have imposed on pharmaceutical companies to the National Institutes of Health (NIH) instead of to the government’s general fund? These valuable funds are being siphoned from research; ethically, from a public health perspective, they should be kept in research. These billions can help one of the NIH institutes such the National Institute of Mental Health (NIMH) establish a psychiatric drug development section to translate biologic discoveries into novel treatments. No such capability exists at the NIMH due to lack of funds.

Legislators. There generally is considerable cynicism about the ethical conduct of politicians, but from psychiatry’s point of view, consider the following:

• Why not use the force of law to enforce parity in insurance coverage?
• Why are legislators willing to appropriate funds to build prisons but not long-term psychiatric hospitals? Is it ethical to criminalize mental illness and incarcerate persons with brain disorders side-by-side with hardened criminals instead of providing them with a dignified and safe medical facility?
• Why don’t legislators fix the broken public mental health system that is underfunded, ineffective, and too bureaucratic for patients and families to navigate?

The media. Although significant improvement has taken place in portraying mental illness compared with a few decades ago, the following unacceptable patterns continue:

• depicting the mentally ill as dangerous killers and “psychos”
• continuing to mock mental illness and addictions as character frailties rather than view them as legitimate illnesses
• failing to expose the injustices that afflict persons with psychiatric brain disorders, including stigma, neglect of physical health needs, inadequate treatment resources (such as availability of inpatient psychiatric beds), or imprisonment in lieu of hospitalization.

Communities. It is regrettable that the negative attitude toward mental illness still is intense enough to perpetuate the vociferous “not in my backyard” (NIMBY) opposition to mental health clinics, residential facilities, or halfway houses. Although the NIMBY syndrome is driven by lack of education and/or understanding of mental illness, ignorance is a poor excuse for ethical shortcomings.

Non-psychiatric physicians. It is quite disheartening to see how prejudiced some internists and surgeons can be toward mentally ill individuals. Most developed a distorted view of psychiatry from being trained decades ago, before the momentous neuroscience advances in psychiatry. But more worrisome are the barriers mentally ill persons face in health care^1-4 that lead to underutilization of routine primary care⁵ and underdiagnosis of serious health conditions.^2,6 Psychiatric patients are less likely to undergo coronary revascularization procedures after a myocardial infarction⁷ or to be properly treated for chronic conditions such as arthritis.⁸ Limited or inadequate medical care has led to early mortality.^9,10 But there is good news from the U.S. Department of Veterans Affairs, where psychiatric patients with diabetes receive as good care as veterans without mental illness¹¹ and have no barriers to nutrition and exercise counseling.¹²

What about our own ethical conduct?

Finally, perhaps psychiatrists should think twice before throwing stones because we, too, may live in ethical “glass houses.” Although we try to adhere to our ethical standards, some of us occasionally may commit ethical peccadilloes, such as:

• continuing to use haloperidol, a 45-year-old drug that has been shown to be neurotoxic in >20 studies over the past decade¹³
• ignoring tier I evidence-based treatments and using unproven modalities that may delay illness resolution
• not regularly monitoring patients for metabolic complications of antipsychotics¹⁴
• not using depot antipsychotics for patients who exhibit violent behavior each time they relapse due to nonadherence
• requiring a drug company representative to bring lunch to the entire clinic staff in return for access to the prescriber.

The quandary with ethics is that they can be too nuanced, enabling almost anyone who breaches an ethical boundary to find a justification. The most unambiguous ethical standards have long been moved from a moral philosophy to codified and legally enforced laws (robbery, assault, rape, homicide, etc.). Psychiatry deals with many groups that have their own version of an “ethics compass.” We psychiatrists have our own ethics standards, which we always aspire to uphold. However, are we so ethically infallible that we can smugly throw stones at people who live in ethical “glass houses?” Doesn’t our ethical “brick house” have glass windows?

Psychiatrists often have to deal with “ethically challenged” entities or individuals. This can be of concern because, ultimately, unethical policies or behavior can harm our patients. However, psychiatrists recognize that what may appear to be unethical to them may not be considered as such by nonpsychiatrists.

Ethics (from Ethos, which means customs) is defined as the standards and rules of conduct that govern a set of human actions by a specific group, profession, or culture. Thus, there are medical ethics, corporate ethics, Christian ethics, student ethics, fishing ethics, etc. Ethics is, therefore, not an absolute standard and may exist only “in the eye of the beholder.” For example, psychiatry as a medical specialty has its own rigorous ethical code that other medical specialties do not uphold (such as prohibiting socializing with patients).

Who are the entities whose ethical transgressions may affect psychiatrists’ work? Consider the following examples:

Insurance companies. Some of their business practices outrage psychiatrists, including:

• vehemently opposing parity for psychiatric brain disorders with other medical disorders
• refusing to cover preexisting conditions
• the preauthorization farce, which costs psychiatrists a large amount of uncompensated time and effort (essentially an unfunded mandate)
• low reimbursement rate for psychiatric care and a bias against coverage for psychotherapy
• forcing stable patients to switch to a cheaper medication that may not work as well, thus potentially destabilizing the patient.

Pharmaceutical companies. Because of intense scrutiny by regulatory and compliance bodies, pharmaceutical companies have largely discontinued questionable practices such as:

• not publishing unfavorable drug data
• minimizing serious side effects such as obesity and diabetes until after their drug is widely used.

However, some companies continue to disconcert psychiatrists and trigger their umbrage by:

• abandoning psychiatric drug development despite the tremendous unmet need and shifting resources to more profitable therapeutic areas
• direct-to-consumer advertising that disrupts the doctor-patient relationship and undermines psychiatrists’ clinical judgment.

The FDA. This key government agency plays an important role in protecting the public, but its policies occasionally spawn ethical dilemmas.

For example, why does it insist that new psychiatric medications be indicated for a DSM “diagnosis” instead of common “symptoms” such as agitation, depression, delusions, hallucinations, anxiety, or impulsivity? DSM diagnoses are arbitrary, committee-created constructs that may change drastically from edition to edition. There is extensive evidence for overlapping symptoms of many psychiatric “diagnoses,” which implies that a drug approved and deemed safe and effective for 1 psychiatric syndrome (eg, psychosis, depression) can help other disorders that share symptoms.

Why doesn’t the FDA channel the billions of dollars in penalties they have imposed on pharmaceutical companies to the National Institutes of Health (NIH) instead of to the government’s general fund? These valuable funds are being siphoned from research; ethically, from a public health perspective, they should be kept in research. These billions can help one of the NIH institutes such the National Institute of Mental Health (NIMH) establish a psychiatric drug development section to translate biologic discoveries into novel treatments. No such capability exists at the NIMH due to lack of funds.

Legislators. There generally is considerable cynicism about the ethical conduct of politicians, but from psychiatry’s point of view, consider the following:

• Why not use the force of law to enforce parity in insurance coverage?
• Why are legislators willing to appropriate funds to build prisons but not long-term psychiatric hospitals? Is it ethical to criminalize mental illness and incarcerate persons with brain disorders side-by-side with hardened criminals instead of providing them with a dignified and safe medical facility?
• Why don’t legislators fix the broken public mental health system that is underfunded, ineffective, and too bureaucratic for patients and families to navigate?

The media. Although significant improvement has taken place in portraying mental illness compared with a few decades ago, the following unacceptable patterns continue:

• depicting the mentally ill as dangerous killers and “psychos”
• continuing to mock mental illness and addictions as character frailties rather than view them as legitimate illnesses
• failing to expose the injustices that afflict persons with psychiatric brain disorders, including stigma, neglect of physical health needs, inadequate treatment resources (such as availability of inpatient psychiatric beds), or imprisonment in lieu of hospitalization.

Communities. It is regrettable that the negative attitude toward mental illness still is intense enough to perpetuate the vociferous “not in my backyard” (NIMBY) opposition to mental health clinics, residential facilities, or halfway houses. Although the NIMBY syndrome is driven by lack of education and/or understanding of mental illness, ignorance is a poor excuse for ethical shortcomings.

Non-psychiatric physicians. It is quite disheartening to see how prejudiced some internists and surgeons can be toward mentally ill individuals. Most developed a distorted view of psychiatry from being trained decades ago, before the momentous neuroscience advances in psychiatry. But more worrisome are the barriers mentally ill persons face in health care^1-4 that lead to underutilization of routine primary care⁵ and underdiagnosis of serious health conditions.^2,6 Psychiatric patients are less likely to undergo coronary revascularization procedures after a myocardial infarction⁷ or to be properly treated for chronic conditions such as arthritis.⁸ Limited or inadequate medical care has led to early mortality.^9,10 But there is good news from the U.S. Department of Veterans Affairs, where psychiatric patients with diabetes receive as good care as veterans without mental illness¹¹ and have no barriers to nutrition and exercise counseling.¹²

What about our own ethical conduct?

Finally, perhaps psychiatrists should think twice before throwing stones because we, too, may live in ethical “glass houses.” Although we try to adhere to our ethical standards, some of us occasionally may commit ethical peccadilloes, such as:

• continuing to use haloperidol, a 45-year-old drug that has been shown to be neurotoxic in >20 studies over the past decade¹³
• ignoring tier I evidence-based treatments and using unproven modalities that may delay illness resolution
• not regularly monitoring patients for metabolic complications of antipsychotics¹⁴
• not using depot antipsychotics for patients who exhibit violent behavior each time they relapse due to nonadherence
• requiring a drug company representative to bring lunch to the entire clinic staff in return for access to the prescriber.

The quandary with ethics is that they can be too nuanced, enabling almost anyone who breaches an ethical boundary to find a justification. The most unambiguous ethical standards have long been moved from a moral philosophy to codified and legally enforced laws (robbery, assault, rape, homicide, etc.). Psychiatry deals with many groups that have their own version of an “ethics compass.” We psychiatrists have our own ethics standards, which we always aspire to uphold. However, are we so ethically infallible that we can smugly throw stones at people who live in ethical “glass houses?” Doesn’t our ethical “brick house” have glass windows?

Psychiatrists often have to deal with “ethically challenged” entities or individuals. This can be of concern because, ultimately, unethical policies or behavior can harm our patients. However, psychiatrists recognize that what may appear to be unethical to them may not be considered as such by nonpsychiatrists.

Ethics (from Ethos, which means customs) is defined as the standards and rules of conduct that govern a set of human actions by a specific group, profession, or culture. Thus, there are medical ethics, corporate ethics, Christian ethics, student ethics, fishing ethics, etc. Ethics is, therefore, not an absolute standard and may exist only “in the eye of the beholder.” For example, psychiatry as a medical specialty has its own rigorous ethical code that other medical specialties do not uphold (such as prohibiting socializing with patients).

Who are the entities whose ethical transgressions may affect psychiatrists’ work? Consider the following examples:

Insurance companies. Some of their business practices outrage psychiatrists, including:

• vehemently opposing parity for psychiatric brain disorders with other medical disorders
• refusing to cover preexisting conditions
• the preauthorization farce, which costs psychiatrists a large amount of uncompensated time and effort (essentially an unfunded mandate)
• low reimbursement rate for psychiatric care and a bias against coverage for psychotherapy
• forcing stable patients to switch to a cheaper medication that may not work as well, thus potentially destabilizing the patient.

Pharmaceutical companies. Because of intense scrutiny by regulatory and compliance bodies, pharmaceutical companies have largely discontinued questionable practices such as:

• not publishing unfavorable drug data
• minimizing serious side effects such as obesity and diabetes until after their drug is widely used.

However, some companies continue to disconcert psychiatrists and trigger their umbrage by:

• abandoning psychiatric drug development despite the tremendous unmet need and shifting resources to more profitable therapeutic areas
• direct-to-consumer advertising that disrupts the doctor-patient relationship and undermines psychiatrists’ clinical judgment.

The FDA. This key government agency plays an important role in protecting the public, but its policies occasionally spawn ethical dilemmas.

For example, why does it insist that new psychiatric medications be indicated for a DSM “diagnosis” instead of common “symptoms” such as agitation, depression, delusions, hallucinations, anxiety, or impulsivity? DSM diagnoses are arbitrary, committee-created constructs that may change drastically from edition to edition. There is extensive evidence for overlapping symptoms of many psychiatric “diagnoses,” which implies that a drug approved and deemed safe and effective for 1 psychiatric syndrome (eg, psychosis, depression) can help other disorders that share symptoms.

Why doesn’t the FDA channel the billions of dollars in penalties they have imposed on pharmaceutical companies to the National Institutes of Health (NIH) instead of to the government’s general fund? These valuable funds are being siphoned from research; ethically, from a public health perspective, they should be kept in research. These billions can help one of the NIH institutes such the National Institute of Mental Health (NIMH) establish a psychiatric drug development section to translate biologic discoveries into novel treatments. No such capability exists at the NIMH due to lack of funds.

Legislators. There generally is considerable cynicism about the ethical conduct of politicians, but from psychiatry’s point of view, consider the following:

• Why not use the force of law to enforce parity in insurance coverage?
• Why are legislators willing to appropriate funds to build prisons but not long-term psychiatric hospitals? Is it ethical to criminalize mental illness and incarcerate persons with brain disorders side-by-side with hardened criminals instead of providing them with a dignified and safe medical facility?
• Why don’t legislators fix the broken public mental health system that is underfunded, ineffective, and too bureaucratic for patients and families to navigate?

The media. Although significant improvement has taken place in portraying mental illness compared with a few decades ago, the following unacceptable patterns continue:

• depicting the mentally ill as dangerous killers and “psychos”
• continuing to mock mental illness and addictions as character frailties rather than view them as legitimate illnesses
• failing to expose the injustices that afflict persons with psychiatric brain disorders, including stigma, neglect of physical health needs, inadequate treatment resources (such as availability of inpatient psychiatric beds), or imprisonment in lieu of hospitalization.

Communities. It is regrettable that the negative attitude toward mental illness still is intense enough to perpetuate the vociferous “not in my backyard” (NIMBY) opposition to mental health clinics, residential facilities, or halfway houses. Although the NIMBY syndrome is driven by lack of education and/or understanding of mental illness, ignorance is a poor excuse for ethical shortcomings.

Non-psychiatric physicians. It is quite disheartening to see how prejudiced some internists and surgeons can be toward mentally ill individuals. Most developed a distorted view of psychiatry from being trained decades ago, before the momentous neuroscience advances in psychiatry. But more worrisome are the barriers mentally ill persons face in health care^1-4 that lead to underutilization of routine primary care⁵ and underdiagnosis of serious health conditions.^2,6 Psychiatric patients are less likely to undergo coronary revascularization procedures after a myocardial infarction⁷ or to be properly treated for chronic conditions such as arthritis.⁸ Limited or inadequate medical care has led to early mortality.^9,10 But there is good news from the U.S. Department of Veterans Affairs, where psychiatric patients with diabetes receive as good care as veterans without mental illness¹¹ and have no barriers to nutrition and exercise counseling.¹²

What about our own ethical conduct?

Finally, perhaps psychiatrists should think twice before throwing stones because we, too, may live in ethical “glass houses.” Although we try to adhere to our ethical standards, some of us occasionally may commit ethical peccadilloes, such as:

• continuing to use haloperidol, a 45-year-old drug that has been shown to be neurotoxic in >20 studies over the past decade¹³
• ignoring tier I evidence-based treatments and using unproven modalities that may delay illness resolution
• not regularly monitoring patients for metabolic complications of antipsychotics¹⁴
• not using depot antipsychotics for patients who exhibit violent behavior each time they relapse due to nonadherence
• requiring a drug company representative to bring lunch to the entire clinic staff in return for access to the prescriber.

The quandary with ethics is that they can be too nuanced, enabling almost anyone who breaches an ethical boundary to find a justification. The most unambiguous ethical standards have long been moved from a moral philosophy to codified and legally enforced laws (robbery, assault, rape, homicide, etc.). Psychiatry deals with many groups that have their own version of an “ethics compass.” We psychiatrists have our own ethics standards, which we always aspire to uphold. However, are we so ethically infallible that we can smugly throw stones at people who live in ethical “glass houses?” Doesn’t our ethical “brick house” have glass windows?

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

Human nature is amazingly diverse. It is replete with behavioral quirks, oddities, eccentricities, and foibles. Most of these are idiosyncrasies that are outside the realm of psychopathology.

Frankly, the world would be a rather boring place without them. Contrary to the allegations that psychiatry medicalizes too many human behaviors that are in the “normal” range, only a small fraction of behavioral deviations are included in axis II of DSM-IV-TR. Unlike common peculiarities, the enduring personality disorders that psychiatrists diagnose and valiantly attempt to treat (no effective pharmacologic treatment has been approved for any of them) usually are significantly maladaptive and could lead to social or vocational dysfunction.

Many individuals exhibit “deplorable” behaviors that generally are frowned upon as a source of concern or are unlawful. Consider greed, bullying, chauvinism, fanaticism, extortion, demagoguery, or corruption. Very few, if any, of those who exhibit such fringe behaviors would consider seeking psychiatric help, although persons irked or injured by them wish they would. And what about bribery, power-seeking, malice, infidelity, laziness, mendacity, cheating, cruelty, narrow-mindedness, ruthlessness, and deceptiveness? Everyone has friends or relatives who exhibit such traits and flaunt them openly as a personal “brand.” Few such individuals would ever regard themselves as truly “flawed” or in need of change or professional help. In fact, those afflicted with such behavioral aberrations that are well outside the socially acceptable norms often are “successful” individuals who occupy prominent business or community roles despite their unendearing, even loathsome conduct. It sometimes appears that they have thrived despite their glaring lack of desirable social traits such as empathy, honesty, generosity, selflessness, and kindness.

Sometimes, it is not the oddities of behavior but extremes of political beliefs that can be most intriguing. They are reminiscent of delusions although they do not meet the DSM definition of delusional thinking (a fixed false belief inconsistent with one’s ethnic, cultural, educational, or religious background). Although real delusions are treatable with medications, para-delusional beliefs are not! A good example is the escalating prevalence of political fanaticism that has permeated society and dominated much of what used to be civilized discourse, even though most of the population continues to uphold middle-of-the-road political beliefs. The ideological polarization has even “infected” some media outlets, especially the free-wheeling blogosphere, where potentially venomous ideas are continuously spawned and instantly disseminated. Those who take diametrically opposite views often extend their conflicts over beliefs and ideas to personal hostilities and ad hominem attacks on “the other side.” This is an excellent example of how the entrenchment of beliefs and attitudes can directly shape behavior and transform an opinion into an “article of faith.”

Fanaticism is a long-standing human trait that has sparked wars and perpetuated prejudice and discrimination. Europe was ravaged by century-long wars instigated and fueled by religious fanaticism, proving that extreme beliefs can not only disrupt individual behavior but can impact cities, countries, and even the world, as depicted by World War II. Interestingly, when bizarre and fringe beliefs and behaviors are manifested on a large scale, it is regarded as political rather than psychopathological. Similarly, when religious beliefs become extreme, as sometimes happens in persons with acute bipolar mania, the unusual verbal output is regarded as a variant of religious exuberance rather than a psychiatric condition, which may delay medical treatment. It seems that in an age of intensifying secularism in developed western countries, political zealotry is the new religion!

Homo sapiens (wise man) is the only species that develops and harbors beliefs and whose behavior is inevitably guided, shaped, and determined by those beliefs. Obviously, some of our species’ beliefs are not consistently “wise,” but tenets can be vital to the health and survival of human individuals and communities. Émile Durkheim, the famous French sociologist, proposed in 1897 that “anomie,” or the lack of norms, values, and beliefs, is the main underpinning of suicide.¹ On the other hand, psychiatrists generally attribute suicide to multiple other factors and anomie rarely is mentioned. However, Durkheim, like all humans, is entitled to his idiosyncratic belief!

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

One of the greatest challenges for busy clinicians, such as Current Psychiatry readers, is keeping up with advances in the field of psychiatry in our limited available time. Because psychiatry is one of the most rapidly expanding medical specialties, psychiatrists, psychiatric nurse practitioners, and other mental health clinicians recognize the importance of ongoing self-driven learning to make sure they are practicing the latest standards of care in diagnosis and treatment.

Although continuously acquiring new knowledge that can improve patient care is stimulating and necessary, it also may be intimidating because most medical journals are packed with studies with arcane methodology, complicated designs, complex statistics, dense tables, and busy figures. Wading through the literature can be time-consuming—and even exhausting—for a busy clinician with limited time to learn the latest research findings, and this approach is not always guaranteed to provide the relevant “take-home nuggets” that can enhance clinical practice.

Enter Current Psychiatry. Established in 2002 as the brainchild of former University of Cincinnati Department of Psychiatry Chair Randy Hillard, MD (now Editor-in-Chief Emeritus) and publisher Thomas Pizor, Current Psychiatry was designed precisely to fill this vital unmet need for busy clinical psychiatrists.¹ Current Psychiatry provides practical, peer-reviewed, evidence-based reviews that are highly relevant to the realities of clinical psychiatric practice. Nationally recognized experts write articles about topics identified as “valued” by practitioners based on systematic surveys of clinicians in various community settings. A diverse editorial board of prominent academic teachers and researchers provides an ongoing stream of diverse articles and perspectives that distill the emerging science and practice of psychiatry into immediately useful applications.

From our first issue, Current Psychiatry has presented information that readers could use to care for their patients, in articles such as:

• Using antipsychotics in patients with dementia (Kasckow JW, et al; February 2004)
• How to reduce mania risk when prescribing stimulants (Dubovsky SL, et al; October 2005)
• Hypnotics and driving: FDA action, clinical trials show need for precautions (Freeman B, et al; April 2007)
• Fibromyalgia: Psychiatric drugs target CNS-linked symptoms (Stanford SB; March 2009)
• The re-emerging role of therapeutic neuromodulation (Janicak PG, et al; November 2010)

The impact has been spectacular. As Current Psychiatry celebrates its 10^th anniversary this month, we can relish its remarkable growth and success. In independent readership surveys, Current Psychiatry has grown to become the most widely read non-tabloid psychiatry journal.² As Editor-in-Chief, I derive great satisfaction from the rave reviews I receive from my colleagues around the country about how they regard Current Psychiatry as their number 1 resource for clinical updates. Stellar feedback such as this indicates that Current Psychiatry clearly meets clinicians’ educational needs.

However, we are not resting on our laurels. Current Psychiatry has continued to innovate and develop new approaches to ongoing self-education by growing its online presence. The offerings at CurrentPsychiatry.com have steadily increased to include the following features:

Online-exclusive content. CurrentPsychiatry.com provides additional resources such as tables, boxes, algorithms, and/or figures related to articles from the printed edition. Later this year, as our 10^th anniversary initiative for you, our readers, Current Psychiatry will offer complete online-exclusive articles that will be listed on the table of contents but published only on CurrentPsychiatry.com.

Multimedia library. Every month, the author of 1 article is invited to participate in a brief (5- to 10-minute) audiocast in which he or she provides additional commentary on clinical topics related to the article. This library currently houses nearly 50 audiocasts. Available at CurrentPsychiatry.com/pages.asp?id=6412.

Continuing Medical Education (CME). This section of our Web site provides peer-reviewed education programs that offer visitors the opportunity to earn free CME credits on a range of clinical topics, including schizophrenia, bipolar disorder, depression, and more. Available at CurrentPsychiatry.com/pages_cme.asp.

Supplements. Recent topics covered in these peer-reviewed, non-CME programs include managing schizophrenia, transcranial magnetic stimulation for depression, and more. Available at CurrentPsychiatry.com/pages_supplement.asp.

Going beyond our printed and online content, Current Psychiatry serves our readers’ educational needs through CME meetings such as the annual Psychiatry Update, which is hosted in conjunction with the American Academy of Clinical Psychiatrists. The next meeting will take place March 29 to 31, 2012 in Chicago, IL and will offer a maximum of 18 AMA PRA Category 1 Credits^TM (For more information, click here.). In addition, Current Psychiatry co-sponsors the University of Cincinnati’s Annual Psychopharmacology Update, which is scheduled for October 20, 2012 in Cincinnati, OH, offering AMA PRA Category 1 Credits^TM.

One of the gratifying aspects of producing a highly relevant educational vehicle such as Current Psychiatry is that my trainees at the University of Cincinnati tell me how useful they find it for their clinical practice. I am glad that they already have developed the good habit of reading Current Psychiatry from cover to cover during their training!

On behalf of Current Psychiatry’s Deputy Editor, Joseph F. Goldberg, MD, our Editorial Consultants, Section Editors, Associate Editors, editorial staff, and publishing staff, we thank you, our loyal readers, for valuing what we do and using the knowledge provided by Current Psychiatry to manage various psychiatric populations with the latest nosological and therapeutic advances. We invite you to continue interacting with us in person, by e-mail, or via CurrentPsychiatry.com and tell us how we can continue to meet your educational needs. We find it very rewarding to hear from you.

Psychiatry is the only medical specialty with a longtime nemesis; it’s called “antipsychiatry,” and it has been active for almost 2 centuries. Although psychiatry has evolved into a major scientific and medical discipline, the century-old primitive stage of psychiatric treatments instigated an antagonism toward psychiatry that persists to the present day.

A recent flurry of books critical of psychiatry is evidence of how the antipsychiatry movement is being propagated by journalists and critics whose views of psychiatry are unflattering despite the abundance of scientific advances that are gradually elucidating the causes and treatments of serious mental disorders.

What are the “wrongdoings” of psychiatry that generate the long-standing protests and assaults? The original “sin” of psychiatry appears to be locking up and “abusing” mentally ill patients in asylums, which 2 centuries ago was considered a humane advance to save seriously disabled patients from homelessness, persecution, neglect, victimization, or imprisonment. The deteriorating conditions of “lunatic” asylums in the 19^th and 20^th centuries were blamed on psychiatry, not the poor funding of such institutions in an era of almost complete ignorance about the medical basis of mental illness. Other perceived misdeeds of psychiatry include:

• Medicalizing madness (contradicting the archaic notion that psychosis is a type of behavior, not an illness)
• Drastic measures to control severe mental illness in the pre-pharmacotherapy era, including excessive use of electroconvulsive therapy (ECT), performing lobotomies, or resecting various body parts
• Use of physical and/or chemical restraints for violent or actively suicidal patients
• Serious or intolerable side effects of some antipsychotic medications
• Labeling slaves’ healthy desire to escape from their masters in the 19^th century as an illness (“drapetomania”)
• Regarding psychoanalysis as unscientific and even harmful
• Labeling homosexuality as a mental disorder until American Psychiatric Association members voted it out of DSM-II in 1973
• The arbitrariness of psychiatric diagnoses based on committee-consensus criteria rather than valid and objective scientific evidence and the lack of biomarkers (this is a legitimate complaint but many physiological tests are being developed)
• Psychoactive drugs allegedly are used to control children (antipsychiatry tends to minimize the existence of serious mental illness among children, although childhood physical diseases are readily accepted)
• Psychiatry is a pseudoscience that pathologizes normal variations of human behaviors, thoughts, or emotions
• Psychiatrists are complicit with drug companies and employ drugs of dubious efficacy (eg, antidepressants) or safety (eg, antipsychotics).

Most of the above reasons are exaggerations or attributed to psychiatry during an era of primitive understanding of psychiatric brain disorders. Harmful interventions such as frontal lobotomy—for which its neurosurgeon inventor received the 1949 Nobel Prize in Medicine—were a product of a desperate time when no effective and safe treatments were available. Although regarded as an effective treatment for mood disorders, ECT certainly was abused many decades ago when it was used (without anesthesia) in patients who were unlikely to benefit from it.

David Cooper¹ coined the term “antipsychiatry” in 1967. Years before him, Michel Foucault propagated a paradigm shift that regarded delusions not as madness or illness, but as a behavioral variant or an “anomaly of judgment.”² That antimedicalization movement was supported by the First Church of Christ, Scientist, the legal system, and even the then-new specialty of neurology, plus social workers and “reformers” who criticized mental hospitals for failing to conduct scientific investigations.³

Formerly institutionalized patients such as Clifford Beers⁴ demanded improvements in shabby state hospital conditions more than a century ago and generated antipsychiatry sentiments in other formerly institutionalized persons. Such antipathy was exacerbated by bizarre psychiatrists such as Henry Cotton at Trenton State Hospital in New Jersey, who advocated that removing various body parts (killing or disfiguring patients) improved mental health.⁵

Other ardent antipsychiatrists included French playwright and former asylum patient Antonin Artaud in the 1920s and psychoanalysts Jacques Lacan and Erich Fromm, who authored antipsychiatry writings from a “secular-humanistic” viewpoint. ECT use in the 1930s and frontal leucotomy in the 1940s understandably intensified fear toward psychiatric therapies. When antipsychotic medications were discovered in the 1950s (eventually helping to shut down most asylums), these medications’ neurologic side effects (dystonia, akathisia, parkinsonism, and tardive dyskinesia) prompted another outcry by antipsychiatry groups, although there was no better alternative to control psychosis.

In the 1950s, a right-wing antipsychiatry movement regarded psychiatry as “subversive, left-wing, anti-American, and communist” because it deprived individuals of their rights. Psychologist Hans Eysenck rejected psychiatric medical approaches in favor of errors in learning as a cause of mental illness (as if learning is not a neurobiologic event).

The 1960s witnessed a surge of antipsychiatry activities by various groups, including prominent psychiatrists such as R.D. Laing, Theodore Lidz, and Silvano Arieti, all of whom argued that psychosis is “understandable” as a method of coping with a “sick society” or due to “schizophrenogenic parents” who inflict damage on their offspring. Thomas Szasz is a prominent psychiatrist who proclaimed mental illness is a myth.⁶ I recall shuddering when he spoke at the University of Rochester during my residency, declaring schizophrenia a myth when I had admitted 3 patients with severe, disabling psychosis earlier that day. I summoned the chutzpah to tell him that in my experience haloperidol surely reduced the symptoms of the so-called “myth”! Szasz collaborated with the Church of Scientology to form the Citizens Commission on Human Rights. Interestingly, Christian Scientists and some fundamental Protestants³ agreed with Szasz’s contention that insanity is a moral, not a medical, issue.

A major impact of the antipsychiatry movement is evident in Italy due to the efforts of Franco Basaglia, an influential “psychiatrist-reformer.” Basaglia was so outraged with the dilapidated and prison-like conditions of mental institutions that he convinced the Italian Parliament to pass a law in 1978⁷ that abruptly dismantled and closed all mental hospitals in Italy. Because of uncontrolled psychosis or mania, many patients who were released ended up in prisons, which had similar or worse repressive conditions as the dismantled asylums. Many chronically hospitalized patients died because of self-neglect or victimization within a few months of their abrupt discharge.

Finally, the antipsychiatry movement aggressively criticizes the pharmaceutical industry’s research, tactics, and influence on psychiatry. Also included in the attacks are academic psychiatrists who conduct FDA clinical trials for new drugs and educate practitioners about the efficacy/safety and indications of new FDA-approved drugs. Although industry research grants are deposited at the investigators’ universities, critics mistakenly assume these psychiatrists personally benefit. The content of all educational programs about psychiatric drugs is strictly restricted to the FDA-approved product label, but critics assume that expert speakers, who are compensated for their time and effort, are promoting the drug rather than educating practitioners about the efficacy, safety, tolerability, and proper use of new medications. Part of the motive for attacking this collaboration is the tenet held by many in the antipsychiatry movement that medications are ineffective, unnecessary, or even dangerous. I wish antipsychiatrists would spend a week on an acute psychiatric unit to witness the need for and benefit from psychotropic medications for psychotic, manic, or depressed patients. Although psychiatric patients experience side effects, they are no worse than those experienced by cancer, arthritis, or diabetes patients.

The antipsychiatry movement is regarded by some as “intellectual halitosis” and by others as a thorn in the side of mainstream psychiatry; most believe that many of its claims are unfair exaggerations based on events and primitive conditions of more than a century ago. However, although irritating and often unfair, antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care.

Psychiatry is the only medical specialty with a longtime nemesis; it’s called “antipsychiatry,” and it has been active for almost 2 centuries. Although psychiatry has evolved into a major scientific and medical discipline, the century-old primitive stage of psychiatric treatments instigated an antagonism toward psychiatry that persists to the present day.

A recent flurry of books critical of psychiatry is evidence of how the antipsychiatry movement is being propagated by journalists and critics whose views of psychiatry are unflattering despite the abundance of scientific advances that are gradually elucidating the causes and treatments of serious mental disorders.

What are the “wrongdoings” of psychiatry that generate the long-standing protests and assaults? The original “sin” of psychiatry appears to be locking up and “abusing” mentally ill patients in asylums, which 2 centuries ago was considered a humane advance to save seriously disabled patients from homelessness, persecution, neglect, victimization, or imprisonment. The deteriorating conditions of “lunatic” asylums in the 19^th and 20^th centuries were blamed on psychiatry, not the poor funding of such institutions in an era of almost complete ignorance about the medical basis of mental illness. Other perceived misdeeds of psychiatry include:

• Medicalizing madness (contradicting the archaic notion that psychosis is a type of behavior, not an illness)
• Drastic measures to control severe mental illness in the pre-pharmacotherapy era, including excessive use of electroconvulsive therapy (ECT), performing lobotomies, or resecting various body parts
• Use of physical and/or chemical restraints for violent or actively suicidal patients
• Serious or intolerable side effects of some antipsychotic medications
• Labeling slaves’ healthy desire to escape from their masters in the 19^th century as an illness (“drapetomania”)
• Regarding psychoanalysis as unscientific and even harmful
• Labeling homosexuality as a mental disorder until American Psychiatric Association members voted it out of DSM-II in 1973
• The arbitrariness of psychiatric diagnoses based on committee-consensus criteria rather than valid and objective scientific evidence and the lack of biomarkers (this is a legitimate complaint but many physiological tests are being developed)
• Psychoactive drugs allegedly are used to control children (antipsychiatry tends to minimize the existence of serious mental illness among children, although childhood physical diseases are readily accepted)
• Psychiatry is a pseudoscience that pathologizes normal variations of human behaviors, thoughts, or emotions
• Psychiatrists are complicit with drug companies and employ drugs of dubious efficacy (eg, antidepressants) or safety (eg, antipsychotics).

Most of the above reasons are exaggerations or attributed to psychiatry during an era of primitive understanding of psychiatric brain disorders. Harmful interventions such as frontal lobotomy—for which its neurosurgeon inventor received the 1949 Nobel Prize in Medicine—were a product of a desperate time when no effective and safe treatments were available. Although regarded as an effective treatment for mood disorders, ECT certainly was abused many decades ago when it was used (without anesthesia) in patients who were unlikely to benefit from it.

David Cooper¹ coined the term “antipsychiatry” in 1967. Years before him, Michel Foucault propagated a paradigm shift that regarded delusions not as madness or illness, but as a behavioral variant or an “anomaly of judgment.”² That antimedicalization movement was supported by the First Church of Christ, Scientist, the legal system, and even the then-new specialty of neurology, plus social workers and “reformers” who criticized mental hospitals for failing to conduct scientific investigations.³

Formerly institutionalized patients such as Clifford Beers⁴ demanded improvements in shabby state hospital conditions more than a century ago and generated antipsychiatry sentiments in other formerly institutionalized persons. Such antipathy was exacerbated by bizarre psychiatrists such as Henry Cotton at Trenton State Hospital in New Jersey, who advocated that removing various body parts (killing or disfiguring patients) improved mental health.⁵

Other ardent antipsychiatrists included French playwright and former asylum patient Antonin Artaud in the 1920s and psychoanalysts Jacques Lacan and Erich Fromm, who authored antipsychiatry writings from a “secular-humanistic” viewpoint. ECT use in the 1930s and frontal leucotomy in the 1940s understandably intensified fear toward psychiatric therapies. When antipsychotic medications were discovered in the 1950s (eventually helping to shut down most asylums), these medications’ neurologic side effects (dystonia, akathisia, parkinsonism, and tardive dyskinesia) prompted another outcry by antipsychiatry groups, although there was no better alternative to control psychosis.

In the 1950s, a right-wing antipsychiatry movement regarded psychiatry as “subversive, left-wing, anti-American, and communist” because it deprived individuals of their rights. Psychologist Hans Eysenck rejected psychiatric medical approaches in favor of errors in learning as a cause of mental illness (as if learning is not a neurobiologic event).

The 1960s witnessed a surge of antipsychiatry activities by various groups, including prominent psychiatrists such as R.D. Laing, Theodore Lidz, and Silvano Arieti, all of whom argued that psychosis is “understandable” as a method of coping with a “sick society” or due to “schizophrenogenic parents” who inflict damage on their offspring. Thomas Szasz is a prominent psychiatrist who proclaimed mental illness is a myth.⁶ I recall shuddering when he spoke at the University of Rochester during my residency, declaring schizophrenia a myth when I had admitted 3 patients with severe, disabling psychosis earlier that day. I summoned the chutzpah to tell him that in my experience haloperidol surely reduced the symptoms of the so-called “myth”! Szasz collaborated with the Church of Scientology to form the Citizens Commission on Human Rights. Interestingly, Christian Scientists and some fundamental Protestants³ agreed with Szasz’s contention that insanity is a moral, not a medical, issue.

A major impact of the antipsychiatry movement is evident in Italy due to the efforts of Franco Basaglia, an influential “psychiatrist-reformer.” Basaglia was so outraged with the dilapidated and prison-like conditions of mental institutions that he convinced the Italian Parliament to pass a law in 1978⁷ that abruptly dismantled and closed all mental hospitals in Italy. Because of uncontrolled psychosis or mania, many patients who were released ended up in prisons, which had similar or worse repressive conditions as the dismantled asylums. Many chronically hospitalized patients died because of self-neglect or victimization within a few months of their abrupt discharge.

Finally, the antipsychiatry movement aggressively criticizes the pharmaceutical industry’s research, tactics, and influence on psychiatry. Also included in the attacks are academic psychiatrists who conduct FDA clinical trials for new drugs and educate practitioners about the efficacy/safety and indications of new FDA-approved drugs. Although industry research grants are deposited at the investigators’ universities, critics mistakenly assume these psychiatrists personally benefit. The content of all educational programs about psychiatric drugs is strictly restricted to the FDA-approved product label, but critics assume that expert speakers, who are compensated for their time and effort, are promoting the drug rather than educating practitioners about the efficacy, safety, tolerability, and proper use of new medications. Part of the motive for attacking this collaboration is the tenet held by many in the antipsychiatry movement that medications are ineffective, unnecessary, or even dangerous. I wish antipsychiatrists would spend a week on an acute psychiatric unit to witness the need for and benefit from psychotropic medications for psychotic, manic, or depressed patients. Although psychiatric patients experience side effects, they are no worse than those experienced by cancer, arthritis, or diabetes patients.

The antipsychiatry movement is regarded by some as “intellectual halitosis” and by others as a thorn in the side of mainstream psychiatry; most believe that many of its claims are unfair exaggerations based on events and primitive conditions of more than a century ago. However, although irritating and often unfair, antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care.

Psychiatry is the only medical specialty with a longtime nemesis; it’s called “antipsychiatry,” and it has been active for almost 2 centuries. Although psychiatry has evolved into a major scientific and medical discipline, the century-old primitive stage of psychiatric treatments instigated an antagonism toward psychiatry that persists to the present day.

A recent flurry of books critical of psychiatry is evidence of how the antipsychiatry movement is being propagated by journalists and critics whose views of psychiatry are unflattering despite the abundance of scientific advances that are gradually elucidating the causes and treatments of serious mental disorders.

What are the “wrongdoings” of psychiatry that generate the long-standing protests and assaults? The original “sin” of psychiatry appears to be locking up and “abusing” mentally ill patients in asylums, which 2 centuries ago was considered a humane advance to save seriously disabled patients from homelessness, persecution, neglect, victimization, or imprisonment. The deteriorating conditions of “lunatic” asylums in the 19^th and 20^th centuries were blamed on psychiatry, not the poor funding of such institutions in an era of almost complete ignorance about the medical basis of mental illness. Other perceived misdeeds of psychiatry include:

• Medicalizing madness (contradicting the archaic notion that psychosis is a type of behavior, not an illness)
• Drastic measures to control severe mental illness in the pre-pharmacotherapy era, including excessive use of electroconvulsive therapy (ECT), performing lobotomies, or resecting various body parts
• Use of physical and/or chemical restraints for violent or actively suicidal patients
• Serious or intolerable side effects of some antipsychotic medications
• Labeling slaves’ healthy desire to escape from their masters in the 19^th century as an illness (“drapetomania”)
• Regarding psychoanalysis as unscientific and even harmful
• Labeling homosexuality as a mental disorder until American Psychiatric Association members voted it out of DSM-II in 1973
• The arbitrariness of psychiatric diagnoses based on committee-consensus criteria rather than valid and objective scientific evidence and the lack of biomarkers (this is a legitimate complaint but many physiological tests are being developed)
• Psychoactive drugs allegedly are used to control children (antipsychiatry tends to minimize the existence of serious mental illness among children, although childhood physical diseases are readily accepted)
• Psychiatry is a pseudoscience that pathologizes normal variations of human behaviors, thoughts, or emotions
• Psychiatrists are complicit with drug companies and employ drugs of dubious efficacy (eg, antidepressants) or safety (eg, antipsychotics).

Most of the above reasons are exaggerations or attributed to psychiatry during an era of primitive understanding of psychiatric brain disorders. Harmful interventions such as frontal lobotomy—for which its neurosurgeon inventor received the 1949 Nobel Prize in Medicine—were a product of a desperate time when no effective and safe treatments were available. Although regarded as an effective treatment for mood disorders, ECT certainly was abused many decades ago when it was used (without anesthesia) in patients who were unlikely to benefit from it.

David Cooper¹ coined the term “antipsychiatry” in 1967. Years before him, Michel Foucault propagated a paradigm shift that regarded delusions not as madness or illness, but as a behavioral variant or an “anomaly of judgment.”² That antimedicalization movement was supported by the First Church of Christ, Scientist, the legal system, and even the then-new specialty of neurology, plus social workers and “reformers” who criticized mental hospitals for failing to conduct scientific investigations.³

Formerly institutionalized patients such as Clifford Beers⁴ demanded improvements in shabby state hospital conditions more than a century ago and generated antipsychiatry sentiments in other formerly institutionalized persons. Such antipathy was exacerbated by bizarre psychiatrists such as Henry Cotton at Trenton State Hospital in New Jersey, who advocated that removing various body parts (killing or disfiguring patients) improved mental health.⁵

Other ardent antipsychiatrists included French playwright and former asylum patient Antonin Artaud in the 1920s and psychoanalysts Jacques Lacan and Erich Fromm, who authored antipsychiatry writings from a “secular-humanistic” viewpoint. ECT use in the 1930s and frontal leucotomy in the 1940s understandably intensified fear toward psychiatric therapies. When antipsychotic medications were discovered in the 1950s (eventually helping to shut down most asylums), these medications’ neurologic side effects (dystonia, akathisia, parkinsonism, and tardive dyskinesia) prompted another outcry by antipsychiatry groups, although there was no better alternative to control psychosis.

In the 1950s, a right-wing antipsychiatry movement regarded psychiatry as “subversive, left-wing, anti-American, and communist” because it deprived individuals of their rights. Psychologist Hans Eysenck rejected psychiatric medical approaches in favor of errors in learning as a cause of mental illness (as if learning is not a neurobiologic event).

The 1960s witnessed a surge of antipsychiatry activities by various groups, including prominent psychiatrists such as R.D. Laing, Theodore Lidz, and Silvano Arieti, all of whom argued that psychosis is “understandable” as a method of coping with a “sick society” or due to “schizophrenogenic parents” who inflict damage on their offspring. Thomas Szasz is a prominent psychiatrist who proclaimed mental illness is a myth.⁶ I recall shuddering when he spoke at the University of Rochester during my residency, declaring schizophrenia a myth when I had admitted 3 patients with severe, disabling psychosis earlier that day. I summoned the chutzpah to tell him that in my experience haloperidol surely reduced the symptoms of the so-called “myth”! Szasz collaborated with the Church of Scientology to form the Citizens Commission on Human Rights. Interestingly, Christian Scientists and some fundamental Protestants³ agreed with Szasz’s contention that insanity is a moral, not a medical, issue.

A major impact of the antipsychiatry movement is evident in Italy due to the efforts of Franco Basaglia, an influential “psychiatrist-reformer.” Basaglia was so outraged with the dilapidated and prison-like conditions of mental institutions that he convinced the Italian Parliament to pass a law in 1978⁷ that abruptly dismantled and closed all mental hospitals in Italy. Because of uncontrolled psychosis or mania, many patients who were released ended up in prisons, which had similar or worse repressive conditions as the dismantled asylums. Many chronically hospitalized patients died because of self-neglect or victimization within a few months of their abrupt discharge.

Finally, the antipsychiatry movement aggressively criticizes the pharmaceutical industry’s research, tactics, and influence on psychiatry. Also included in the attacks are academic psychiatrists who conduct FDA clinical trials for new drugs and educate practitioners about the efficacy/safety and indications of new FDA-approved drugs. Although industry research grants are deposited at the investigators’ universities, critics mistakenly assume these psychiatrists personally benefit. The content of all educational programs about psychiatric drugs is strictly restricted to the FDA-approved product label, but critics assume that expert speakers, who are compensated for their time and effort, are promoting the drug rather than educating practitioners about the efficacy, safety, tolerability, and proper use of new medications. Part of the motive for attacking this collaboration is the tenet held by many in the antipsychiatry movement that medications are ineffective, unnecessary, or even dangerous. I wish antipsychiatrists would spend a week on an acute psychiatric unit to witness the need for and benefit from psychotropic medications for psychotic, manic, or depressed patients. Although psychiatric patients experience side effects, they are no worse than those experienced by cancer, arthritis, or diabetes patients.

The antipsychiatry movement is regarded by some as “intellectual halitosis” and by others as a thorn in the side of mainstream psychiatry; most believe that many of its claims are unfair exaggerations based on events and primitive conditions of more than a century ago. However, although irritating and often unfair, antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care.

What makes a first-class psychiatrist? What are the traits that characterize the “ideal” psychiatrist? How does a good psychiatrist become great? There are many possible answers depending on who is asked.

In my view, after observing countless fellow psychiatrists over 3 decades in various settings, I have concluded there are 7 domains that determine the caliber of psychiatrists that we all aspire to be. It may be difficult to possess all the traits across all 7 domains but I propose it as an idealized model and a road map for the journey toward peak performance in our profession.

Domain I: Personal attributes

• The ability to listen “actively” and observe “comprehensively”
• Psychological mindedness and curiosity
• Skillfully engages and develops therapeutic alliance with patients from the first encounter
• Compassion and empathy, but pragmatic firmness about boundaries
• Nonjudgmental stance and cognizance of one’s own limitations
• Impeccable integrity and ethical conduct.

Domain II: Clinical mastery

• Thorough familiarity with the principles of psychiatry and models of behavior and psychopathology
• Rigor in applying a diagnostic label by employing the skills of a physician to check patients’ medical status to rule out general medical etiologies; monitors patients’ physical and mental health and refers as needed
• Establishes a skillful biopsychosocial treatment plan requiring extensive knowledge of psychopharmacology and psychotherapy
• Applies evidence-based interventions wherever available
• Always checks and deals with countertransference issues.

Domain III: Professionalism and leadership

• Always well dressed and groomed with a professional appearance; projects the identity of being a physician; leadership of mental health teams
• Involved in local, state, national, and international professional societies
• Raises the profile of psychiatry within the medical field by networking with other physician organizations and participating in medical initiatives.

Domain IV: Organizational effectiveness

• Leads balanced and well organized professional and personal lives
• Smooth working relationship with individuals or agencies relevant to the patient’s treatment, including family members, medical and mental health professionals, hospital administrators, clinics, insurance companies, advocacy groups, and the legal system
• Maintains an organized and complete medical record with measurement-based ratings of illness severity and side effects.

Domain V: Societal role

• Establishes one’s self as a role model for those seeking advice and guidance not only for psychiatric disorders, but for various societal dilemmas and is an effective communicator
• Feels comfortable in being a public figure in one’s community whose opinions are valued by laymen as well as other professionals
• Serves as an ambassador for the profession by educating the public via various media outlets to erase misperceptions about mental illness or psychiatry, and to rebut and neutralize the occasional venomous assaults recklessly hurled by antipsychiatry cults.

Domain VI: Lifelong learning

• Convinced of the need for continuous learning in an era of logarithmic growth of medical knowledge
• Reads several articles a week from key journals about recent clinical and scientific advances and applies them to patients when appropriate
• Attends or presents at continuing medical education meetings and asks questions or makes comments (active, not passive attendance).

Domain VII: Contribution to new knowledge

• Recognizes the vast unmet needs in psychiatry, supports research, and understands that the research of today is the better treatment of tomorrow
• Refers patients to clinical research protocols at the local academic institution and offers to collaborate as a rater or data collector
• Takes the time to write up unusual clinical cases as a letter to the editor or case report and generate new clinical ideas
• If not a full-time academic, volunteers to teach or supervise medical students or residents at the local medical school or teaching hospital.

Very few psychiatrists can excel at all 7 domains, but most meet the criteria for several of them. Every psychiatrist can move from good to great with a modicum of effort and motivation. If most of us do that, the caliber and standing of our psychiatric profession will continue to escalate.

What makes a first-class psychiatrist? What are the traits that characterize the “ideal” psychiatrist? How does a good psychiatrist become great? There are many possible answers depending on who is asked.

In my view, after observing countless fellow psychiatrists over 3 decades in various settings, I have concluded there are 7 domains that determine the caliber of psychiatrists that we all aspire to be. It may be difficult to possess all the traits across all 7 domains but I propose it as an idealized model and a road map for the journey toward peak performance in our profession.

Domain I: Personal attributes

• The ability to listen “actively” and observe “comprehensively”
• Psychological mindedness and curiosity
• Skillfully engages and develops therapeutic alliance with patients from the first encounter
• Compassion and empathy, but pragmatic firmness about boundaries
• Nonjudgmental stance and cognizance of one’s own limitations
• Impeccable integrity and ethical conduct.

Domain II: Clinical mastery

• Thorough familiarity with the principles of psychiatry and models of behavior and psychopathology
• Rigor in applying a diagnostic label by employing the skills of a physician to check patients’ medical status to rule out general medical etiologies; monitors patients’ physical and mental health and refers as needed
• Establishes a skillful biopsychosocial treatment plan requiring extensive knowledge of psychopharmacology and psychotherapy
• Applies evidence-based interventions wherever available
• Always checks and deals with countertransference issues.

Domain III: Professionalism and leadership

• Always well dressed and groomed with a professional appearance; projects the identity of being a physician; leadership of mental health teams
• Involved in local, state, national, and international professional societies
• Raises the profile of psychiatry within the medical field by networking with other physician organizations and participating in medical initiatives.

Domain IV: Organizational effectiveness

• Leads balanced and well organized professional and personal lives
• Smooth working relationship with individuals or agencies relevant to the patient’s treatment, including family members, medical and mental health professionals, hospital administrators, clinics, insurance companies, advocacy groups, and the legal system
• Maintains an organized and complete medical record with measurement-based ratings of illness severity and side effects.

Domain V: Societal role

• Establishes one’s self as a role model for those seeking advice and guidance not only for psychiatric disorders, but for various societal dilemmas and is an effective communicator
• Feels comfortable in being a public figure in one’s community whose opinions are valued by laymen as well as other professionals
• Serves as an ambassador for the profession by educating the public via various media outlets to erase misperceptions about mental illness or psychiatry, and to rebut and neutralize the occasional venomous assaults recklessly hurled by antipsychiatry cults.

Domain VI: Lifelong learning

• Convinced of the need for continuous learning in an era of logarithmic growth of medical knowledge
• Reads several articles a week from key journals about recent clinical and scientific advances and applies them to patients when appropriate
• Attends or presents at continuing medical education meetings and asks questions or makes comments (active, not passive attendance).

Domain VII: Contribution to new knowledge

• Recognizes the vast unmet needs in psychiatry, supports research, and understands that the research of today is the better treatment of tomorrow
• Refers patients to clinical research protocols at the local academic institution and offers to collaborate as a rater or data collector
• Takes the time to write up unusual clinical cases as a letter to the editor or case report and generate new clinical ideas
• If not a full-time academic, volunteers to teach or supervise medical students or residents at the local medical school or teaching hospital.

Very few psychiatrists can excel at all 7 domains, but most meet the criteria for several of them. Every psychiatrist can move from good to great with a modicum of effort and motivation. If most of us do that, the caliber and standing of our psychiatric profession will continue to escalate.

What makes a first-class psychiatrist? What are the traits that characterize the “ideal” psychiatrist? How does a good psychiatrist become great? There are many possible answers depending on who is asked.

In my view, after observing countless fellow psychiatrists over 3 decades in various settings, I have concluded there are 7 domains that determine the caliber of psychiatrists that we all aspire to be. It may be difficult to possess all the traits across all 7 domains but I propose it as an idealized model and a road map for the journey toward peak performance in our profession.

Domain I: Personal attributes

• The ability to listen “actively” and observe “comprehensively”
• Psychological mindedness and curiosity
• Skillfully engages and develops therapeutic alliance with patients from the first encounter
• Compassion and empathy, but pragmatic firmness about boundaries
• Nonjudgmental stance and cognizance of one’s own limitations
• Impeccable integrity and ethical conduct.

Domain II: Clinical mastery

• Thorough familiarity with the principles of psychiatry and models of behavior and psychopathology
• Rigor in applying a diagnostic label by employing the skills of a physician to check patients’ medical status to rule out general medical etiologies; monitors patients’ physical and mental health and refers as needed
• Establishes a skillful biopsychosocial treatment plan requiring extensive knowledge of psychopharmacology and psychotherapy
• Applies evidence-based interventions wherever available
• Always checks and deals with countertransference issues.

Domain III: Professionalism and leadership

• Always well dressed and groomed with a professional appearance; projects the identity of being a physician; leadership of mental health teams
• Involved in local, state, national, and international professional societies
• Raises the profile of psychiatry within the medical field by networking with other physician organizations and participating in medical initiatives.

Domain IV: Organizational effectiveness

• Leads balanced and well organized professional and personal lives
• Smooth working relationship with individuals or agencies relevant to the patient’s treatment, including family members, medical and mental health professionals, hospital administrators, clinics, insurance companies, advocacy groups, and the legal system
• Maintains an organized and complete medical record with measurement-based ratings of illness severity and side effects.

Domain V: Societal role

• Establishes one’s self as a role model for those seeking advice and guidance not only for psychiatric disorders, but for various societal dilemmas and is an effective communicator
• Feels comfortable in being a public figure in one’s community whose opinions are valued by laymen as well as other professionals
• Serves as an ambassador for the profession by educating the public via various media outlets to erase misperceptions about mental illness or psychiatry, and to rebut and neutralize the occasional venomous assaults recklessly hurled by antipsychiatry cults.

Domain VI: Lifelong learning

• Convinced of the need for continuous learning in an era of logarithmic growth of medical knowledge
• Reads several articles a week from key journals about recent clinical and scientific advances and applies them to patients when appropriate
• Attends or presents at continuing medical education meetings and asks questions or makes comments (active, not passive attendance).

Domain VII: Contribution to new knowledge

• Recognizes the vast unmet needs in psychiatry, supports research, and understands that the research of today is the better treatment of tomorrow
• Refers patients to clinical research protocols at the local academic institution and offers to collaborate as a rater or data collector
• Takes the time to write up unusual clinical cases as a letter to the editor or case report and generate new clinical ideas
• If not a full-time academic, volunteers to teach or supervise medical students or residents at the local medical school or teaching hospital.

Very few psychiatrists can excel at all 7 domains, but most meet the criteria for several of them. Every psychiatrist can move from good to great with a modicum of effort and motivation. If most of us do that, the caliber and standing of our psychiatric profession will continue to escalate.