Henry A. Nasrallah, MD

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Research

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.

Investigators. Psychiatrists and neuroscientists who dedicate their lives to discovering the causes and treatments of psychiatric brain disorders by conducting basic, translational, or clinical research spend countless hours designing, writing, and submitting grant proposals that have a <10% chance of getting funded. They work long hours to discover new knowledge despite limited resources. They move our field forward with cutting-edge discoveries.

Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.

Clinicians. Colleagues who refer their patients to research studies are supporting discovery of new knowledge and without them new psychiatric drug development would slow down considerably.

Reviewers of grants and journal articles. It takes a great deal of expertise and time to identify grants worthy of receiving taxpayer support or to review and recommend the best articles for publication in leading psychiatric journals. Many distinguished researchers—who often are clinicians—donate enormous amounts of uncompensated time to these essential tasks. For a list of colleagues who served as Current Psychiatry peer reviewers in 2010.

Interactive clinicians find time to send in letters to the editor about an unusual clinical observation that may generate new research ideas.

Clinical

Psychiatrists and nurse practitioners, who put in far more than the 40-hour work week to meet the need for psychiatric care caused by the severe shortage of psychiatric clinicians in the United States. They sacrifice their personal needs to help others.

Pro bono clinicians, who donate their services without compensation to those who are indigent or uninsured.

Assertive Community Treatment team members, who reach out to the homeless and seriously sick patients who are the most challenging.

Psychiatric nurses, who are the frontline mental health professionals on psychiatric inpatient units and in psychiatric emergency rooms. They deserve our gratitude and thanks.

Families, whose love and dedication to their mentally ill family members can be critical for seeking psychiatric care or adhering to treatment.

Teaching

Teaching faculty, who provide education and training for physicians, psychiatrists, and nurse practitioners of the future. This includes volunteer (unpaid) faculty who donate their time to supervise psychiatric trainees. They prepare the future generations of clinicians, researchers, and teachers.

Mentors, who may be clinicians, researchers, or both, providing personal guidance, coaching, support and role-models for young trainees or early-career psychiatrists, often shaping their lives and careers. Their generosity and generativity are priceless.

Service

Psychiatrists, who actively participate in their local, state, and national professional societies. I estimate that 10% of the members of any association do the bulk of the work to accomplish the stated mission.

Advocacy groups such as the National Alliance on Mental Illness, Mental Health America, and others who do so much to help persons suffering from psychiatric disorders and whose public service advances the cause of our patients and the mental health field.

Colleagues who step forward and do the gut-wrenching but necessary task of turning in colleagues who commit unethical or illegal acts or who come to work intoxicated. These individuals ensure the integrity of the specialty and prompt their colleagues to seek help.

Celebrities and public figures who openly discuss their personal or family struggles with psychiatric illness. They help diminish stigma, enhance the public’s willingness to seek psychiatric care, and reduce discrimination.

I tip my proverbial hat to all the above heroes. Their ongoing contributions are vital for our profession, and they deserve our gratitude.

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Research

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.

Investigators. Psychiatrists and neuroscientists who dedicate their lives to discovering the causes and treatments of psychiatric brain disorders by conducting basic, translational, or clinical research spend countless hours designing, writing, and submitting grant proposals that have a <10% chance of getting funded. They work long hours to discover new knowledge despite limited resources. They move our field forward with cutting-edge discoveries.

Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.

Clinicians. Colleagues who refer their patients to research studies are supporting discovery of new knowledge and without them new psychiatric drug development would slow down considerably.

Reviewers of grants and journal articles. It takes a great deal of expertise and time to identify grants worthy of receiving taxpayer support or to review and recommend the best articles for publication in leading psychiatric journals. Many distinguished researchers—who often are clinicians—donate enormous amounts of uncompensated time to these essential tasks. For a list of colleagues who served as Current Psychiatry peer reviewers in 2010.

Interactive clinicians find time to send in letters to the editor about an unusual clinical observation that may generate new research ideas.

Clinical

Psychiatrists and nurse practitioners, who put in far more than the 40-hour work week to meet the need for psychiatric care caused by the severe shortage of psychiatric clinicians in the United States. They sacrifice their personal needs to help others.

Pro bono clinicians, who donate their services without compensation to those who are indigent or uninsured.

Assertive Community Treatment team members, who reach out to the homeless and seriously sick patients who are the most challenging.

Psychiatric nurses, who are the frontline mental health professionals on psychiatric inpatient units and in psychiatric emergency rooms. They deserve our gratitude and thanks.

Families, whose love and dedication to their mentally ill family members can be critical for seeking psychiatric care or adhering to treatment.

Teaching

Teaching faculty, who provide education and training for physicians, psychiatrists, and nurse practitioners of the future. This includes volunteer (unpaid) faculty who donate their time to supervise psychiatric trainees. They prepare the future generations of clinicians, researchers, and teachers.

Mentors, who may be clinicians, researchers, or both, providing personal guidance, coaching, support and role-models for young trainees or early-career psychiatrists, often shaping their lives and careers. Their generosity and generativity are priceless.

Service

Psychiatrists, who actively participate in their local, state, and national professional societies. I estimate that 10% of the members of any association do the bulk of the work to accomplish the stated mission.

Advocacy groups such as the National Alliance on Mental Illness, Mental Health America, and others who do so much to help persons suffering from psychiatric disorders and whose public service advances the cause of our patients and the mental health field.

Colleagues who step forward and do the gut-wrenching but necessary task of turning in colleagues who commit unethical or illegal acts or who come to work intoxicated. These individuals ensure the integrity of the specialty and prompt their colleagues to seek help.

Celebrities and public figures who openly discuss their personal or family struggles with psychiatric illness. They help diminish stigma, enhance the public’s willingness to seek psychiatric care, and reduce discrimination.

I tip my proverbial hat to all the above heroes. Their ongoing contributions are vital for our profession, and they deserve our gratitude.

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Research

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.

Investigators. Psychiatrists and neuroscientists who dedicate their lives to discovering the causes and treatments of psychiatric brain disorders by conducting basic, translational, or clinical research spend countless hours designing, writing, and submitting grant proposals that have a <10% chance of getting funded. They work long hours to discover new knowledge despite limited resources. They move our field forward with cutting-edge discoveries.

Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.

Clinicians. Colleagues who refer their patients to research studies are supporting discovery of new knowledge and without them new psychiatric drug development would slow down considerably.

Reviewers of grants and journal articles. It takes a great deal of expertise and time to identify grants worthy of receiving taxpayer support or to review and recommend the best articles for publication in leading psychiatric journals. Many distinguished researchers—who often are clinicians—donate enormous amounts of uncompensated time to these essential tasks. For a list of colleagues who served as Current Psychiatry peer reviewers in 2010.

Interactive clinicians find time to send in letters to the editor about an unusual clinical observation that may generate new research ideas.

Clinical

Psychiatrists and nurse practitioners, who put in far more than the 40-hour work week to meet the need for psychiatric care caused by the severe shortage of psychiatric clinicians in the United States. They sacrifice their personal needs to help others.

Pro bono clinicians, who donate their services without compensation to those who are indigent or uninsured.

Assertive Community Treatment team members, who reach out to the homeless and seriously sick patients who are the most challenging.

Psychiatric nurses, who are the frontline mental health professionals on psychiatric inpatient units and in psychiatric emergency rooms. They deserve our gratitude and thanks.

Families, whose love and dedication to their mentally ill family members can be critical for seeking psychiatric care or adhering to treatment.

Teaching

Teaching faculty, who provide education and training for physicians, psychiatrists, and nurse practitioners of the future. This includes volunteer (unpaid) faculty who donate their time to supervise psychiatric trainees. They prepare the future generations of clinicians, researchers, and teachers.

Mentors, who may be clinicians, researchers, or both, providing personal guidance, coaching, support and role-models for young trainees or early-career psychiatrists, often shaping their lives and careers. Their generosity and generativity are priceless.

Service

Psychiatrists, who actively participate in their local, state, and national professional societies. I estimate that 10% of the members of any association do the bulk of the work to accomplish the stated mission.

Advocacy groups such as the National Alliance on Mental Illness, Mental Health America, and others who do so much to help persons suffering from psychiatric disorders and whose public service advances the cause of our patients and the mental health field.

Colleagues who step forward and do the gut-wrenching but necessary task of turning in colleagues who commit unethical or illegal acts or who come to work intoxicated. These individuals ensure the integrity of the specialty and prompt their colleagues to seek help.

Celebrities and public figures who openly discuss their personal or family struggles with psychiatric illness. They help diminish stigma, enhance the public’s willingness to seek psychiatric care, and reduce discrimination.

I tip my proverbial hat to all the above heroes. Their ongoing contributions are vital for our profession, and they deserve our gratitude.

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms. Consider the following:

Major depressive disorder (MDD). The most prominent symptoms of MDD are feelings of “worthlessness” and “hopelessness.” Patients with clinical depression almost always believe—even if they are successful people—that they are failures, awful people, or a burden on their families. They also often believe that there is no hope for them, no way out of their rut and misery, and that death by suicide is the only option. Yet such patients—who clearly have reality distortion and who harbor a completely false view of themselves, the world, and the future—are not regarded as having a psychosis, but a standard depressive episode and are generally treated with antidepressants. Only when depressed patients express a paranoid idea or that their body is full of excrement or that God is punishing them for their evil acts are they given the diagnosis of “psychotic depression,” and an antipsychotic is considered a necessary adjunct to their antidepressant regimen.

But isn’t there just a dimensional difference in the severity of the delusion between MDD and psychotic depression? Shouldn’t worthlessness and hopelessness be regarded as psychotic symptoms congruent with the mood disorder? Interestingly, 2 atypical antipsychotics—aripiprazole and quetiapine—have been FDA-approved as add-on therapy for patients who do not respond to 1 or 2 antidepressants. Could the D2 dopamine antagonism exerted by antipsychotics be the reason for the stronger antidepressant response?

Obsessive-compulsive disorder (OCD). Is it not a fixed false belief when a person suffering from OCD washes his hands 50 to 100 times a day until his skin is raw because of the erroneous belief that his hands are dirty? Is it not psychosis when an OCD patient performs hours of daily rituals that render her dysfunctional because she falsely believes that unless she performs the rituals “something terrible will happen” to her or her loved ones?

Anxiety disorder. How about the reality distortion of anxiety disorder patients who would never board a plane because they falsely believe it will crash or will not drive over a bridge or in a tunnel because they believe it will collapse? Even when such false beliefs impair patients’ functioning, clinicians do not regard it as a psychosis but as “anxiety fear.” Is fear not the essence of paranoia?

Anorexia nervosa (AN). Is a severely emaciated AN patient’s fixed false belief that he or she is fat—which can be life-threatening—not a form of psychosis?

Body dysmorphic disorder (BDD). The completely unwarranted or fallacious perception of ugliness or blemishes in a BDD patient are a form of fixed false beliefs that may lead to functional disability or dozens of plastic surgeries. Regardless of whether a perceptual disturbance is involved, the phenotype qualifies as a psychotic disorder.

Hypochondriasis. When a person adamantly and falsely believes that he has a serious physical disease and expends time, effort, and money doctor-shopping to receive treatment for an illusory somatic ailment, why do we label it as a somatoform disorder instead of a somatic delusion? Interestingly, DSM-IV-TR criterion C of hypochondriasis specifies that the preoccupation of having a serious disease should not be of “delusional intensity (as in delusional disorder, somatic type).” What is the definition of delusional intensity? At what point does a false belief move from mild to intense status and becomes psychotic?

Personality disorders. Consider how various thematic false beliefs pervade several axis II disorders, such as paranoid, schizotypal, borderline, narcissistic, or avoidant personality disorders. They all have an enduring component of a fixed false belief that falls on the continuum of psychosis.

By now, some readers may have arrived at the conclusion that this editor has developed his own fixed false belief that practically all psychiatric disorders are psychotic! Well, not exactly, but I did intend to provoke you to reconsider what we take for granted in the DSM, where psychotic disorders are set aside as just one section of 17 types of disorders. At least I hope that I convinced you that a thread of psychotic thinking can be identified across many of the other 16 supposedly “nonpsychotic” groupings.

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms. Consider the following:

Major depressive disorder (MDD). The most prominent symptoms of MDD are feelings of “worthlessness” and “hopelessness.” Patients with clinical depression almost always believe—even if they are successful people—that they are failures, awful people, or a burden on their families. They also often believe that there is no hope for them, no way out of their rut and misery, and that death by suicide is the only option. Yet such patients—who clearly have reality distortion and who harbor a completely false view of themselves, the world, and the future—are not regarded as having a psychosis, but a standard depressive episode and are generally treated with antidepressants. Only when depressed patients express a paranoid idea or that their body is full of excrement or that God is punishing them for their evil acts are they given the diagnosis of “psychotic depression,” and an antipsychotic is considered a necessary adjunct to their antidepressant regimen.

But isn’t there just a dimensional difference in the severity of the delusion between MDD and psychotic depression? Shouldn’t worthlessness and hopelessness be regarded as psychotic symptoms congruent with the mood disorder? Interestingly, 2 atypical antipsychotics—aripiprazole and quetiapine—have been FDA-approved as add-on therapy for patients who do not respond to 1 or 2 antidepressants. Could the D2 dopamine antagonism exerted by antipsychotics be the reason for the stronger antidepressant response?

Obsessive-compulsive disorder (OCD). Is it not a fixed false belief when a person suffering from OCD washes his hands 50 to 100 times a day until his skin is raw because of the erroneous belief that his hands are dirty? Is it not psychosis when an OCD patient performs hours of daily rituals that render her dysfunctional because she falsely believes that unless she performs the rituals “something terrible will happen” to her or her loved ones?

Anxiety disorder. How about the reality distortion of anxiety disorder patients who would never board a plane because they falsely believe it will crash or will not drive over a bridge or in a tunnel because they believe it will collapse? Even when such false beliefs impair patients’ functioning, clinicians do not regard it as a psychosis but as “anxiety fear.” Is fear not the essence of paranoia?

Anorexia nervosa (AN). Is a severely emaciated AN patient’s fixed false belief that he or she is fat—which can be life-threatening—not a form of psychosis?

Body dysmorphic disorder (BDD). The completely unwarranted or fallacious perception of ugliness or blemishes in a BDD patient are a form of fixed false beliefs that may lead to functional disability or dozens of plastic surgeries. Regardless of whether a perceptual disturbance is involved, the phenotype qualifies as a psychotic disorder.

Hypochondriasis. When a person adamantly and falsely believes that he has a serious physical disease and expends time, effort, and money doctor-shopping to receive treatment for an illusory somatic ailment, why do we label it as a somatoform disorder instead of a somatic delusion? Interestingly, DSM-IV-TR criterion C of hypochondriasis specifies that the preoccupation of having a serious disease should not be of “delusional intensity (as in delusional disorder, somatic type).” What is the definition of delusional intensity? At what point does a false belief move from mild to intense status and becomes psychotic?

Personality disorders. Consider how various thematic false beliefs pervade several axis II disorders, such as paranoid, schizotypal, borderline, narcissistic, or avoidant personality disorders. They all have an enduring component of a fixed false belief that falls on the continuum of psychosis.

By now, some readers may have arrived at the conclusion that this editor has developed his own fixed false belief that practically all psychiatric disorders are psychotic! Well, not exactly, but I did intend to provoke you to reconsider what we take for granted in the DSM, where psychotic disorders are set aside as just one section of 17 types of disorders. At least I hope that I convinced you that a thread of psychotic thinking can be identified across many of the other 16 supposedly “nonpsychotic” groupings.

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms. Consider the following:

Major depressive disorder (MDD). The most prominent symptoms of MDD are feelings of “worthlessness” and “hopelessness.” Patients with clinical depression almost always believe—even if they are successful people—that they are failures, awful people, or a burden on their families. They also often believe that there is no hope for them, no way out of their rut and misery, and that death by suicide is the only option. Yet such patients—who clearly have reality distortion and who harbor a completely false view of themselves, the world, and the future—are not regarded as having a psychosis, but a standard depressive episode and are generally treated with antidepressants. Only when depressed patients express a paranoid idea or that their body is full of excrement or that God is punishing them for their evil acts are they given the diagnosis of “psychotic depression,” and an antipsychotic is considered a necessary adjunct to their antidepressant regimen.

But isn’t there just a dimensional difference in the severity of the delusion between MDD and psychotic depression? Shouldn’t worthlessness and hopelessness be regarded as psychotic symptoms congruent with the mood disorder? Interestingly, 2 atypical antipsychotics—aripiprazole and quetiapine—have been FDA-approved as add-on therapy for patients who do not respond to 1 or 2 antidepressants. Could the D2 dopamine antagonism exerted by antipsychotics be the reason for the stronger antidepressant response?

Obsessive-compulsive disorder (OCD). Is it not a fixed false belief when a person suffering from OCD washes his hands 50 to 100 times a day until his skin is raw because of the erroneous belief that his hands are dirty? Is it not psychosis when an OCD patient performs hours of daily rituals that render her dysfunctional because she falsely believes that unless she performs the rituals “something terrible will happen” to her or her loved ones?

Anxiety disorder. How about the reality distortion of anxiety disorder patients who would never board a plane because they falsely believe it will crash or will not drive over a bridge or in a tunnel because they believe it will collapse? Even when such false beliefs impair patients’ functioning, clinicians do not regard it as a psychosis but as “anxiety fear.” Is fear not the essence of paranoia?

Anorexia nervosa (AN). Is a severely emaciated AN patient’s fixed false belief that he or she is fat—which can be life-threatening—not a form of psychosis?

Body dysmorphic disorder (BDD). The completely unwarranted or fallacious perception of ugliness or blemishes in a BDD patient are a form of fixed false beliefs that may lead to functional disability or dozens of plastic surgeries. Regardless of whether a perceptual disturbance is involved, the phenotype qualifies as a psychotic disorder.

Hypochondriasis. When a person adamantly and falsely believes that he has a serious physical disease and expends time, effort, and money doctor-shopping to receive treatment for an illusory somatic ailment, why do we label it as a somatoform disorder instead of a somatic delusion? Interestingly, DSM-IV-TR criterion C of hypochondriasis specifies that the preoccupation of having a serious disease should not be of “delusional intensity (as in delusional disorder, somatic type).” What is the definition of delusional intensity? At what point does a false belief move from mild to intense status and becomes psychotic?

Personality disorders. Consider how various thematic false beliefs pervade several axis II disorders, such as paranoid, schizotypal, borderline, narcissistic, or avoidant personality disorders. They all have an enduring component of a fixed false belief that falls on the continuum of psychosis.

By now, some readers may have arrived at the conclusion that this editor has developed his own fixed false belief that practically all psychiatric disorders are psychotic! Well, not exactly, but I did intend to provoke you to reconsider what we take for granted in the DSM, where psychotic disorders are set aside as just one section of 17 types of disorders. At least I hope that I convinced you that a thread of psychotic thinking can be identified across many of the other 16 supposedly “nonpsychotic” groupings.

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

• What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?
• Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?
• What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?
• How long should a session be? How was the weekly 50-minute session determined? Why not 10, 20, 30, or 40 minutes? Is 15 minutes 3 times a week more or less effective than 50 minutes once a week?
• What is the primary indication for a given psychotherapy? Why do therapists use the same psychotherapy for many different psychiatric disorders? Isn’t that like giving the same drug to everyone with any psychiatric illness? Is there such a thing as using a psychotherapeutic technique “off-label”? Why don’t therapy techniques come with a label like drug therapy?
• What is the best time of day to conduct psychotherapy to achieve maximum benefit? Patients are assigned a slot almost randomly between 8 am and 5 pm, but is early morning psychotherapy more effective than, say, mid-afternoon? Could going to sleep immediately after a session help consolidate memories, insights, learning, and emotional processing more than returning to one’s work setting or home, where many distractions may disrupt or erase the salutary neurobiologic effects of psychotherapy? If this could be proven with controlled studies then perhaps patients could schedule a nap right after a session in a dark cubicle adjacent to the therapist’s suite? This could result in a boom of “psychotherapy motels!”
• What effect does food have on psychotherapy efficacy? Is an empty stomach and hunger better or worse for patients? Would the borborygmi be distracting to some therapists? Is there a possible benefit for a postprandial session when serum glucose levels are higher? Could cognition be sharper for assimilating psychotherapy after eating vs before?
• Does ambient light intensity impact psychotherapy? Could ultra-bright light that is used for seasonal depression (10,000 lux vs the usual 100 lux fluorescent bulbs) placed in a patient’s field of vision during a session accentuate psychotherapy’s beneficial effects?
• What are the side effects of psychotherapy? Why is it assumed that psychotherapy exerts efficacy without any tolerability or safety problems? Can certain types of psychotherapy cause somatic adverse effects—such as headache, nausea, dizziness, or appetite and sleep changes—that are unwittingly attributed to the psychiatric illness rather than the treatment?
• Is there such a thing as psychotherapy overdose? What is it and what are its symptoms? Is it initiated by the patient, the therapist, or both?
• Could co-administration of modest doses of neurogenesis-enhancing drugs such as a selective serotonin reuptake inhibitor or lithium potentiate the effects of psychotherapy, because learning and memory are improved with neurogenesis-associated hippocampal growth?
• Does psychotherapy work differently in different age groups (adolescent vs adult vs middle age vs elderly) because of ongoing brain circuitry and neuroplastic changes throughout the life cycle?
• Are there “me too” psychotherapies similar to “me too” drugs?
• Can a combination of 2 or 3 different psychotherapies work better than a single psychotherapy? Could cognitive-behavioral therapy combined with psychodynamic psychotherapy exert higher efficacy then either alone?
• Assuming that ongoing psychotherapy costs about $100 per session and a patient receives 40 to 50 sessions a year for a total of $4,000 to $5,000 a year, why the outcry about medications that cost a similar amount?
• Is the adherence rate to psychotherapy similar to that of pharmacotherapy? Do some patients “intellectually cheek” an occasional psychotherapeutic dose?
• Is there a generic psychotherapy? Is it cheaper? Is it as good as “brand-name” psychotherapy?

I am sure readers realize that some of my questions are serious while others are tongue-in-cheek, but I hope my musings prompt you to join me in thinking outside the box about psychotherapy and the many gaps of knowledge that persist. Rigorous research is needed to substantiate or negate some current assumptions about the use of psychotherapy.

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

• What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?
• Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?
• What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?
• How long should a session be? How was the weekly 50-minute session determined? Why not 10, 20, 30, or 40 minutes? Is 15 minutes 3 times a week more or less effective than 50 minutes once a week?
• What is the primary indication for a given psychotherapy? Why do therapists use the same psychotherapy for many different psychiatric disorders? Isn’t that like giving the same drug to everyone with any psychiatric illness? Is there such a thing as using a psychotherapeutic technique “off-label”? Why don’t therapy techniques come with a label like drug therapy?
• What is the best time of day to conduct psychotherapy to achieve maximum benefit? Patients are assigned a slot almost randomly between 8 am and 5 pm, but is early morning psychotherapy more effective than, say, mid-afternoon? Could going to sleep immediately after a session help consolidate memories, insights, learning, and emotional processing more than returning to one’s work setting or home, where many distractions may disrupt or erase the salutary neurobiologic effects of psychotherapy? If this could be proven with controlled studies then perhaps patients could schedule a nap right after a session in a dark cubicle adjacent to the therapist’s suite? This could result in a boom of “psychotherapy motels!”
• What effect does food have on psychotherapy efficacy? Is an empty stomach and hunger better or worse for patients? Would the borborygmi be distracting to some therapists? Is there a possible benefit for a postprandial session when serum glucose levels are higher? Could cognition be sharper for assimilating psychotherapy after eating vs before?
• Does ambient light intensity impact psychotherapy? Could ultra-bright light that is used for seasonal depression (10,000 lux vs the usual 100 lux fluorescent bulbs) placed in a patient’s field of vision during a session accentuate psychotherapy’s beneficial effects?
• What are the side effects of psychotherapy? Why is it assumed that psychotherapy exerts efficacy without any tolerability or safety problems? Can certain types of psychotherapy cause somatic adverse effects—such as headache, nausea, dizziness, or appetite and sleep changes—that are unwittingly attributed to the psychiatric illness rather than the treatment?
• Is there such a thing as psychotherapy overdose? What is it and what are its symptoms? Is it initiated by the patient, the therapist, or both?
• Could co-administration of modest doses of neurogenesis-enhancing drugs such as a selective serotonin reuptake inhibitor or lithium potentiate the effects of psychotherapy, because learning and memory are improved with neurogenesis-associated hippocampal growth?
• Does psychotherapy work differently in different age groups (adolescent vs adult vs middle age vs elderly) because of ongoing brain circuitry and neuroplastic changes throughout the life cycle?
• Are there “me too” psychotherapies similar to “me too” drugs?
• Can a combination of 2 or 3 different psychotherapies work better than a single psychotherapy? Could cognitive-behavioral therapy combined with psychodynamic psychotherapy exert higher efficacy then either alone?
• Assuming that ongoing psychotherapy costs about $100 per session and a patient receives 40 to 50 sessions a year for a total of $4,000 to $5,000 a year, why the outcry about medications that cost a similar amount?
• Is the adherence rate to psychotherapy similar to that of pharmacotherapy? Do some patients “intellectually cheek” an occasional psychotherapeutic dose?
• Is there a generic psychotherapy? Is it cheaper? Is it as good as “brand-name” psychotherapy?

I am sure readers realize that some of my questions are serious while others are tongue-in-cheek, but I hope my musings prompt you to join me in thinking outside the box about psychotherapy and the many gaps of knowledge that persist. Rigorous research is needed to substantiate or negate some current assumptions about the use of psychotherapy.

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

• What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?
• Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?
• What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?
• How long should a session be? How was the weekly 50-minute session determined? Why not 10, 20, 30, or 40 minutes? Is 15 minutes 3 times a week more or less effective than 50 minutes once a week?
• What is the primary indication for a given psychotherapy? Why do therapists use the same psychotherapy for many different psychiatric disorders? Isn’t that like giving the same drug to everyone with any psychiatric illness? Is there such a thing as using a psychotherapeutic technique “off-label”? Why don’t therapy techniques come with a label like drug therapy?
• What is the best time of day to conduct psychotherapy to achieve maximum benefit? Patients are assigned a slot almost randomly between 8 am and 5 pm, but is early morning psychotherapy more effective than, say, mid-afternoon? Could going to sleep immediately after a session help consolidate memories, insights, learning, and emotional processing more than returning to one’s work setting or home, where many distractions may disrupt or erase the salutary neurobiologic effects of psychotherapy? If this could be proven with controlled studies then perhaps patients could schedule a nap right after a session in a dark cubicle adjacent to the therapist’s suite? This could result in a boom of “psychotherapy motels!”
• What effect does food have on psychotherapy efficacy? Is an empty stomach and hunger better or worse for patients? Would the borborygmi be distracting to some therapists? Is there a possible benefit for a postprandial session when serum glucose levels are higher? Could cognition be sharper for assimilating psychotherapy after eating vs before?
• Does ambient light intensity impact psychotherapy? Could ultra-bright light that is used for seasonal depression (10,000 lux vs the usual 100 lux fluorescent bulbs) placed in a patient’s field of vision during a session accentuate psychotherapy’s beneficial effects?
• What are the side effects of psychotherapy? Why is it assumed that psychotherapy exerts efficacy without any tolerability or safety problems? Can certain types of psychotherapy cause somatic adverse effects—such as headache, nausea, dizziness, or appetite and sleep changes—that are unwittingly attributed to the psychiatric illness rather than the treatment?
• Is there such a thing as psychotherapy overdose? What is it and what are its symptoms? Is it initiated by the patient, the therapist, or both?
• Could co-administration of modest doses of neurogenesis-enhancing drugs such as a selective serotonin reuptake inhibitor or lithium potentiate the effects of psychotherapy, because learning and memory are improved with neurogenesis-associated hippocampal growth?
• Does psychotherapy work differently in different age groups (adolescent vs adult vs middle age vs elderly) because of ongoing brain circuitry and neuroplastic changes throughout the life cycle?
• Are there “me too” psychotherapies similar to “me too” drugs?
• Can a combination of 2 or 3 different psychotherapies work better than a single psychotherapy? Could cognitive-behavioral therapy combined with psychodynamic psychotherapy exert higher efficacy then either alone?
• Assuming that ongoing psychotherapy costs about $100 per session and a patient receives 40 to 50 sessions a year for a total of $4,000 to $5,000 a year, why the outcry about medications that cost a similar amount?
• Is the adherence rate to psychotherapy similar to that of pharmacotherapy? Do some patients “intellectually cheek” an occasional psychotherapeutic dose?
• Is there a generic psychotherapy? Is it cheaper? Is it as good as “brand-name” psychotherapy?

I am sure readers realize that some of my questions are serious while others are tongue-in-cheek, but I hope my musings prompt you to join me in thinking outside the box about psychotherapy and the many gaps of knowledge that persist. Rigorous research is needed to substantiate or negate some current assumptions about the use of psychotherapy.

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur:

Geographic separation. Freestanding psychiatric hospitals completely detached from medical/surgical services perpetuate the old misconception that psychiatric disorders are different despite overwhelming scientific evidence that all mental disorders are medical brain disorders.

The same holds for outpatient care. Established about 50 years ago, community mental health centers (CMHCs) around the country operate separately from primary care clinics despite the high prevalence of general medical disorders among psychiatric patients, and the equally high prevalence of psychiatric disorders among primary care patients.

CMHCs perpetuate an old psychosocial model dominated by non-medical mental health professionals, although patients in those settings have severe brain disorders and need a comprehensive medical approach. Because function follows structure, this geographic separation inevitably contributes to the perception that psychiatric disorders are not really medical disorders but some kind of psychosocial maladaptiveness.

Financial separation. Psychiatric care has never been reimbursed on par with medical/surgical care, although all specialties, including psychiatry, diagnose and treat diseases of various body organs. The egregious injustice of this disparity (go ahead, call it discrimination) is truly shocking for the damage it has inflicted on tens of millions of psychiatric patients, their families, and their psychiatrists. Recently, parity has been pledged in federal laws, but remains a pipe dream for many, as insurance companies and businesses resist its implementation.

Organizational separation. The psychiatric/medical records of millions of patients with serious mental brain disorders are kept separate from their general medical records. This is universally true in CMHCs, which keep their own records, thus preventing collaborative care with primary care providers. This could lead to misdiagnosis, medical errors, duplicate lab tests, adverse drug-drug interactions, and lack of appropriate and timely primary care interventions. Some HMOs—where integrated care is a primary goal—still keep psychiatric records separately. The VA does a good job with unified records but access to psychiatric data is restricted. The intense confidentiality of psychiatric information compared with general medical information evokes a perception that psychiatric history and symptoms should not be accessed as is diabetes, hypertension, or cancer history. Could transparency be an antidote to the stigma of mental illness?

Cultural separation. Most people with serious psychiatric brain disorders receive care at CMHCs, where they are referred to as “clients” instead of “patients,” as though treating mental illness is a business transaction! No other medical specialty has abandoned the term “patient,” which immediately implies having a medical ailment that requires medical attention. Non-medical language contributes to an unnecessary separation from the rest of medicine.

Forensic separation. No other medical specialty has half of its patients in jails and prisons! Imagine if medical symptoms like coughing, wheezing, or vomiting lead to incarceration, as agitation or bizarre psychotic behavior frequently do. The criminalization of psychiatric disorders is an unconscionable travesty and a mark of shame on our country, which housed mentally ill individuals in state hospitals before the destructive tsunami of deinstitutionalization dismantled these facilities under the mantra of “least restrictive environment” and ironically replaced them with correctional facilities. The preponderance of legalistic intrusions into psychiatry inevitably spawned the booming subspecialty of forensic psychiatry. I don’t think there will ever be a forensic gastroenterologist or a forensic hematologist or a forensic oncologist.

So how do we eliminate those chasms and complete the full integration of psychiatry into the rest of medicine? It is not easy and it will take time, but a good start is to co-locate psychiatric care with primary care, unify medical records, achieve full insurance parity, and uphold the medical model with adjunctive psychosocial supports. A possible catalyst for this transformation would be for psychiatrists to regain their leadership roles in psychiatric health care and work under the rubric of psychiatry as a medical specialty.

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur:

Geographic separation. Freestanding psychiatric hospitals completely detached from medical/surgical services perpetuate the old misconception that psychiatric disorders are different despite overwhelming scientific evidence that all mental disorders are medical brain disorders.

The same holds for outpatient care. Established about 50 years ago, community mental health centers (CMHCs) around the country operate separately from primary care clinics despite the high prevalence of general medical disorders among psychiatric patients, and the equally high prevalence of psychiatric disorders among primary care patients.

CMHCs perpetuate an old psychosocial model dominated by non-medical mental health professionals, although patients in those settings have severe brain disorders and need a comprehensive medical approach. Because function follows structure, this geographic separation inevitably contributes to the perception that psychiatric disorders are not really medical disorders but some kind of psychosocial maladaptiveness.

Financial separation. Psychiatric care has never been reimbursed on par with medical/surgical care, although all specialties, including psychiatry, diagnose and treat diseases of various body organs. The egregious injustice of this disparity (go ahead, call it discrimination) is truly shocking for the damage it has inflicted on tens of millions of psychiatric patients, their families, and their psychiatrists. Recently, parity has been pledged in federal laws, but remains a pipe dream for many, as insurance companies and businesses resist its implementation.

Organizational separation. The psychiatric/medical records of millions of patients with serious mental brain disorders are kept separate from their general medical records. This is universally true in CMHCs, which keep their own records, thus preventing collaborative care with primary care providers. This could lead to misdiagnosis, medical errors, duplicate lab tests, adverse drug-drug interactions, and lack of appropriate and timely primary care interventions. Some HMOs—where integrated care is a primary goal—still keep psychiatric records separately. The VA does a good job with unified records but access to psychiatric data is restricted. The intense confidentiality of psychiatric information compared with general medical information evokes a perception that psychiatric history and symptoms should not be accessed as is diabetes, hypertension, or cancer history. Could transparency be an antidote to the stigma of mental illness?

Cultural separation. Most people with serious psychiatric brain disorders receive care at CMHCs, where they are referred to as “clients” instead of “patients,” as though treating mental illness is a business transaction! No other medical specialty has abandoned the term “patient,” which immediately implies having a medical ailment that requires medical attention. Non-medical language contributes to an unnecessary separation from the rest of medicine.

Forensic separation. No other medical specialty has half of its patients in jails and prisons! Imagine if medical symptoms like coughing, wheezing, or vomiting lead to incarceration, as agitation or bizarre psychotic behavior frequently do. The criminalization of psychiatric disorders is an unconscionable travesty and a mark of shame on our country, which housed mentally ill individuals in state hospitals before the destructive tsunami of deinstitutionalization dismantled these facilities under the mantra of “least restrictive environment” and ironically replaced them with correctional facilities. The preponderance of legalistic intrusions into psychiatry inevitably spawned the booming subspecialty of forensic psychiatry. I don’t think there will ever be a forensic gastroenterologist or a forensic hematologist or a forensic oncologist.

So how do we eliminate those chasms and complete the full integration of psychiatry into the rest of medicine? It is not easy and it will take time, but a good start is to co-locate psychiatric care with primary care, unify medical records, achieve full insurance parity, and uphold the medical model with adjunctive psychosocial supports. A possible catalyst for this transformation would be for psychiatrists to regain their leadership roles in psychiatric health care and work under the rubric of psychiatry as a medical specialty.

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur:

Geographic separation. Freestanding psychiatric hospitals completely detached from medical/surgical services perpetuate the old misconception that psychiatric disorders are different despite overwhelming scientific evidence that all mental disorders are medical brain disorders.

The same holds for outpatient care. Established about 50 years ago, community mental health centers (CMHCs) around the country operate separately from primary care clinics despite the high prevalence of general medical disorders among psychiatric patients, and the equally high prevalence of psychiatric disorders among primary care patients.

CMHCs perpetuate an old psychosocial model dominated by non-medical mental health professionals, although patients in those settings have severe brain disorders and need a comprehensive medical approach. Because function follows structure, this geographic separation inevitably contributes to the perception that psychiatric disorders are not really medical disorders but some kind of psychosocial maladaptiveness.

Financial separation. Psychiatric care has never been reimbursed on par with medical/surgical care, although all specialties, including psychiatry, diagnose and treat diseases of various body organs. The egregious injustice of this disparity (go ahead, call it discrimination) is truly shocking for the damage it has inflicted on tens of millions of psychiatric patients, their families, and their psychiatrists. Recently, parity has been pledged in federal laws, but remains a pipe dream for many, as insurance companies and businesses resist its implementation.

Organizational separation. The psychiatric/medical records of millions of patients with serious mental brain disorders are kept separate from their general medical records. This is universally true in CMHCs, which keep their own records, thus preventing collaborative care with primary care providers. This could lead to misdiagnosis, medical errors, duplicate lab tests, adverse drug-drug interactions, and lack of appropriate and timely primary care interventions. Some HMOs—where integrated care is a primary goal—still keep psychiatric records separately. The VA does a good job with unified records but access to psychiatric data is restricted. The intense confidentiality of psychiatric information compared with general medical information evokes a perception that psychiatric history and symptoms should not be accessed as is diabetes, hypertension, or cancer history. Could transparency be an antidote to the stigma of mental illness?

Cultural separation. Most people with serious psychiatric brain disorders receive care at CMHCs, where they are referred to as “clients” instead of “patients,” as though treating mental illness is a business transaction! No other medical specialty has abandoned the term “patient,” which immediately implies having a medical ailment that requires medical attention. Non-medical language contributes to an unnecessary separation from the rest of medicine.

Forensic separation. No other medical specialty has half of its patients in jails and prisons! Imagine if medical symptoms like coughing, wheezing, or vomiting lead to incarceration, as agitation or bizarre psychotic behavior frequently do. The criminalization of psychiatric disorders is an unconscionable travesty and a mark of shame on our country, which housed mentally ill individuals in state hospitals before the destructive tsunami of deinstitutionalization dismantled these facilities under the mantra of “least restrictive environment” and ironically replaced them with correctional facilities. The preponderance of legalistic intrusions into psychiatry inevitably spawned the booming subspecialty of forensic psychiatry. I don’t think there will ever be a forensic gastroenterologist or a forensic hematologist or a forensic oncologist.

So how do we eliminate those chasms and complete the full integration of psychiatry into the rest of medicine? It is not easy and it will take time, but a good start is to co-locate psychiatric care with primary care, unify medical records, achieve full insurance parity, and uphold the medical model with adjunctive psychosocial supports. A possible catalyst for this transformation would be for psychiatrists to regain their leadership roles in psychiatric health care and work under the rubric of psychiatry as a medical specialty.

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

There is nothing wrong with treating patients based on up-to-date practice guidelines and evidence-based principles of clinical effectiveness. The issue is whether clinical decisions should be made by the physician, one patient at a time, rather than imposing the dreaded “cookie-cutter” approach of protocols or algorithms on a population of patients whose only commonality is a DSM-IV-TR diagnosis. The not-so-hidden agenda of the business-oriented managed care systems is to lower costs, not to provide the best personalized medical care. Who came up with the absurd notion that there is such a thing as “an average patient” who would respond to a prepackaged, economically efficient “average treatment”? That is a serious disservice to the spectrum of patients suffering from psychiatric illnesses and an insult to skilled, compassionate psychiatrists who can provide customized care to each patient.

It is certainly paradoxical that at a time when personalized medicine is advocated as “best practice” in medical care, managed care health systems are propagating and implementing a contrarian movement of homogenizing treatment into rigid protocols with a preset, algorithmic approach. These competing messages create a confusing state of cognitive dissonance, especially for trainees, as to how clinicians should deliver medical care for their patients.

It is well known that a large proportion of psychiatric disorders (>80%) have no evidence-based, FDA-approved treatments, and no practice guidelines, protocols, or standards of care.¹ This is where psychiatrists have to use more art than science—including the necessary, but often maligned, off-label treatments—to help reduce their patients’ suffering. In these situations, the physician-patient relationship simply cannot be superseded by any prepackaged protocol, and physicians should decide what is best for their patient.

So let physicians unite behind what makes medicine such a noble profession: combining the best available scientific knowledge with experience and well-honed clinical judgment to deliver customized care, one patient at a time. We must treat our patients exactly as we want to be treated when we inevitably suffer from an illness.

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

There is nothing wrong with treating patients based on up-to-date practice guidelines and evidence-based principles of clinical effectiveness. The issue is whether clinical decisions should be made by the physician, one patient at a time, rather than imposing the dreaded “cookie-cutter” approach of protocols or algorithms on a population of patients whose only commonality is a DSM-IV-TR diagnosis. The not-so-hidden agenda of the business-oriented managed care systems is to lower costs, not to provide the best personalized medical care. Who came up with the absurd notion that there is such a thing as “an average patient” who would respond to a prepackaged, economically efficient “average treatment”? That is a serious disservice to the spectrum of patients suffering from psychiatric illnesses and an insult to skilled, compassionate psychiatrists who can provide customized care to each patient.

It is certainly paradoxical that at a time when personalized medicine is advocated as “best practice” in medical care, managed care health systems are propagating and implementing a contrarian movement of homogenizing treatment into rigid protocols with a preset, algorithmic approach. These competing messages create a confusing state of cognitive dissonance, especially for trainees, as to how clinicians should deliver medical care for their patients.

It is well known that a large proportion of psychiatric disorders (>80%) have no evidence-based, FDA-approved treatments, and no practice guidelines, protocols, or standards of care.¹ This is where psychiatrists have to use more art than science—including the necessary, but often maligned, off-label treatments—to help reduce their patients’ suffering. In these situations, the physician-patient relationship simply cannot be superseded by any prepackaged protocol, and physicians should decide what is best for their patient.

So let physicians unite behind what makes medicine such a noble profession: combining the best available scientific knowledge with experience and well-honed clinical judgment to deliver customized care, one patient at a time. We must treat our patients exactly as we want to be treated when we inevitably suffer from an illness.

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

There is nothing wrong with treating patients based on up-to-date practice guidelines and evidence-based principles of clinical effectiveness. The issue is whether clinical decisions should be made by the physician, one patient at a time, rather than imposing the dreaded “cookie-cutter” approach of protocols or algorithms on a population of patients whose only commonality is a DSM-IV-TR diagnosis. The not-so-hidden agenda of the business-oriented managed care systems is to lower costs, not to provide the best personalized medical care. Who came up with the absurd notion that there is such a thing as “an average patient” who would respond to a prepackaged, economically efficient “average treatment”? That is a serious disservice to the spectrum of patients suffering from psychiatric illnesses and an insult to skilled, compassionate psychiatrists who can provide customized care to each patient.

It is certainly paradoxical that at a time when personalized medicine is advocated as “best practice” in medical care, managed care health systems are propagating and implementing a contrarian movement of homogenizing treatment into rigid protocols with a preset, algorithmic approach. These competing messages create a confusing state of cognitive dissonance, especially for trainees, as to how clinicians should deliver medical care for their patients.

It is well known that a large proportion of psychiatric disorders (>80%) have no evidence-based, FDA-approved treatments, and no practice guidelines, protocols, or standards of care.¹ This is where psychiatrists have to use more art than science—including the necessary, but often maligned, off-label treatments—to help reduce their patients’ suffering. In these situations, the physician-patient relationship simply cannot be superseded by any prepackaged protocol, and physicians should decide what is best for their patient.

So let physicians unite behind what makes medicine such a noble profession: combining the best available scientific knowledge with experience and well-honed clinical judgment to deliver customized care, one patient at a time. We must treat our patients exactly as we want to be treated when we inevitably suffer from an illness.

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities.

Diagnostic lab tests. Biomarkers for psychiatric disorders will, in the near future, help our specialty transcend the DSM’s syndromal approach and help us more decisively clinch diagnoses and proceed to specific treatment. The biggest challenge remains the etiologic heterogeneity of psychiatric disorders, which can undermine the reliability of a single test. I predict that a combination of tests will have to be used to confirm a given clinical diagnosis.

Pharmacogenetics. Momentous advances have been made in identifying cytochrome enzyme mutations that render individuals poor metabolizers or extensive metabolizers; yet few clinicians have access to a laboratory to provide them with their patients’ cytochrome activity profile so they can select the right dose to maximize response and minimize side effects. Furthermore, research is proceeding to identify genes and single nucleotide polymorphisms that predict response to a given antipsychotic, antidepressant, or mood stabilizer. Similarly, pharmacogenetic research is pursuing methods of predicting patients’ potential to develop a specific adverse event but these methods are not yet accessible in clinical settings and the cost remains prohibitive.

Brave new formulations. Despite evidence of high rates of nonadherence with oral medications among schizophrenia patients, long-acting antipsychotics that ensure adherence are used infrequently. Patches and sublingual tablets are now available. The future may bring additional formulations with advantages such as immediate onset of action (eg, intravenous antidepressants or mood stabilizers) or more localized CNS activity (eg, intrathecal antipsychotic drug administration) to avoid organ-system complications. Inhalable formulations may be around the corner and could offer quicker onset of efficacy.

Neuroimaging-guided psychotherapy. Functional magnetic resonance imaging (fMRI), which shows what brain region is activated, some day will enable psychotherapists to visualize their patients’ brain activity in real time as they evoke memories, elicit insight, or trigger anger or sadness. The emotional and cognitive circuitry will provide a road map of patients’ mental archaeology and may help document psychotherapeutic response and recovery.

Brain repair. Evidence indicates that ailing brains can be structurally repaired. Brain disorders such as schizophrenia, bipolar disorder, unipolar depression, and OCD show gray and white matter deterioration, and acute episodes often are associated with detrimental neuroplastic changes. Advances in neuroprotection, neurogenesis, neurotrophic factors, and antiapoptotic cascades will give psychiatrists a toolbox to regenerate, reconnect, and resculpt brain regions in their patients by using specific pharmacologic agents and evidence-based psychotherapy.

Deep brain stimulation (DBS). Of all neurostimulation techniques, DBS may have the most promising psychiatric applications. Studies suggest applications for refractory depression, OCD, or psychosis. The future will bring insights into how DBS can used to bring back to life a dormant corner of the brain or turn off a rogue neural circuit. DBS is a standard treatment for Parkinson’s disease and may become so for psychiatric conditions.

The future can fulfill our dreams and aspirations for curing or preventing psychiatric illness. But let us not forget that only intensive research can accelerate our future. Everything we know today was a research project a few years ago and the research of today is the treatment of tomorrow. Thus, recruiting more psychiatrists into research careers is a key and indispensable ingredient for a brighter future for us and our patients.

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities.

Diagnostic lab tests. Biomarkers for psychiatric disorders will, in the near future, help our specialty transcend the DSM’s syndromal approach and help us more decisively clinch diagnoses and proceed to specific treatment. The biggest challenge remains the etiologic heterogeneity of psychiatric disorders, which can undermine the reliability of a single test. I predict that a combination of tests will have to be used to confirm a given clinical diagnosis.

Pharmacogenetics. Momentous advances have been made in identifying cytochrome enzyme mutations that render individuals poor metabolizers or extensive metabolizers; yet few clinicians have access to a laboratory to provide them with their patients’ cytochrome activity profile so they can select the right dose to maximize response and minimize side effects. Furthermore, research is proceeding to identify genes and single nucleotide polymorphisms that predict response to a given antipsychotic, antidepressant, or mood stabilizer. Similarly, pharmacogenetic research is pursuing methods of predicting patients’ potential to develop a specific adverse event but these methods are not yet accessible in clinical settings and the cost remains prohibitive.

Brave new formulations. Despite evidence of high rates of nonadherence with oral medications among schizophrenia patients, long-acting antipsychotics that ensure adherence are used infrequently. Patches and sublingual tablets are now available. The future may bring additional formulations with advantages such as immediate onset of action (eg, intravenous antidepressants or mood stabilizers) or more localized CNS activity (eg, intrathecal antipsychotic drug administration) to avoid organ-system complications. Inhalable formulations may be around the corner and could offer quicker onset of efficacy.

Neuroimaging-guided psychotherapy. Functional magnetic resonance imaging (fMRI), which shows what brain region is activated, some day will enable psychotherapists to visualize their patients’ brain activity in real time as they evoke memories, elicit insight, or trigger anger or sadness. The emotional and cognitive circuitry will provide a road map of patients’ mental archaeology and may help document psychotherapeutic response and recovery.

Brain repair. Evidence indicates that ailing brains can be structurally repaired. Brain disorders such as schizophrenia, bipolar disorder, unipolar depression, and OCD show gray and white matter deterioration, and acute episodes often are associated with detrimental neuroplastic changes. Advances in neuroprotection, neurogenesis, neurotrophic factors, and antiapoptotic cascades will give psychiatrists a toolbox to regenerate, reconnect, and resculpt brain regions in their patients by using specific pharmacologic agents and evidence-based psychotherapy.

Deep brain stimulation (DBS). Of all neurostimulation techniques, DBS may have the most promising psychiatric applications. Studies suggest applications for refractory depression, OCD, or psychosis. The future will bring insights into how DBS can used to bring back to life a dormant corner of the brain or turn off a rogue neural circuit. DBS is a standard treatment for Parkinson’s disease and may become so for psychiatric conditions.

The future can fulfill our dreams and aspirations for curing or preventing psychiatric illness. But let us not forget that only intensive research can accelerate our future. Everything we know today was a research project a few years ago and the research of today is the treatment of tomorrow. Thus, recruiting more psychiatrists into research careers is a key and indispensable ingredient for a brighter future for us and our patients.

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities.

Diagnostic lab tests. Biomarkers for psychiatric disorders will, in the near future, help our specialty transcend the DSM’s syndromal approach and help us more decisively clinch diagnoses and proceed to specific treatment. The biggest challenge remains the etiologic heterogeneity of psychiatric disorders, which can undermine the reliability of a single test. I predict that a combination of tests will have to be used to confirm a given clinical diagnosis.

Pharmacogenetics. Momentous advances have been made in identifying cytochrome enzyme mutations that render individuals poor metabolizers or extensive metabolizers; yet few clinicians have access to a laboratory to provide them with their patients’ cytochrome activity profile so they can select the right dose to maximize response and minimize side effects. Furthermore, research is proceeding to identify genes and single nucleotide polymorphisms that predict response to a given antipsychotic, antidepressant, or mood stabilizer. Similarly, pharmacogenetic research is pursuing methods of predicting patients’ potential to develop a specific adverse event but these methods are not yet accessible in clinical settings and the cost remains prohibitive.

Brave new formulations. Despite evidence of high rates of nonadherence with oral medications among schizophrenia patients, long-acting antipsychotics that ensure adherence are used infrequently. Patches and sublingual tablets are now available. The future may bring additional formulations with advantages such as immediate onset of action (eg, intravenous antidepressants or mood stabilizers) or more localized CNS activity (eg, intrathecal antipsychotic drug administration) to avoid organ-system complications. Inhalable formulations may be around the corner and could offer quicker onset of efficacy.

Neuroimaging-guided psychotherapy. Functional magnetic resonance imaging (fMRI), which shows what brain region is activated, some day will enable psychotherapists to visualize their patients’ brain activity in real time as they evoke memories, elicit insight, or trigger anger or sadness. The emotional and cognitive circuitry will provide a road map of patients’ mental archaeology and may help document psychotherapeutic response and recovery.

Brain repair. Evidence indicates that ailing brains can be structurally repaired. Brain disorders such as schizophrenia, bipolar disorder, unipolar depression, and OCD show gray and white matter deterioration, and acute episodes often are associated with detrimental neuroplastic changes. Advances in neuroprotection, neurogenesis, neurotrophic factors, and antiapoptotic cascades will give psychiatrists a toolbox to regenerate, reconnect, and resculpt brain regions in their patients by using specific pharmacologic agents and evidence-based psychotherapy.

Deep brain stimulation (DBS). Of all neurostimulation techniques, DBS may have the most promising psychiatric applications. Studies suggest applications for refractory depression, OCD, or psychosis. The future will bring insights into how DBS can used to bring back to life a dormant corner of the brain or turn off a rogue neural circuit. DBS is a standard treatment for Parkinson’s disease and may become so for psychiatric conditions.

The future can fulfill our dreams and aspirations for curing or preventing psychiatric illness. But let us not forget that only intensive research can accelerate our future. Everything we know today was a research project a few years ago and the research of today is the treatment of tomorrow. Thus, recruiting more psychiatrists into research careers is a key and indispensable ingredient for a brighter future for us and our patients.

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?

Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.¹ It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.² Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.³

Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.

Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?

Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?

Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.⁴ Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?

Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.⁵

Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.⁶ What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.

Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.

Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses:

Unipolar depression. Blier et al¹ demonstrated a remarkable superiority of 3 different combinations of 2 antidepressants compared with fluoxetine monotherapy. The remission rate with combination therapy (46% to 58%) was double that of fluoxetine alone (25%). When 1 of the 2 antidepressants was blindly discontinued in high responders, 40% relapsed. Tolerability to the combination was the same as to monotherapy. Recent FDA approval of 2 atypical antipsychotics—aripiprazole² and quetiapine³—as adjuncts to antidepressants to increase the remission rates further supports the case for combination therapy.

Bipolar disorder. Psychiatrists know that combining a mood stabilizer with an antipsychotic exerts more efficacy that either drug alone.⁴ But what about combining 2 mood stabilizers? A recent study⁵ confirmed the superiority of combining lithium plus valproate compared with either 1 alone. Score another victory for polypharmacy in bipolar disorder, where FDA studies of combination therapy are more common than in any other psychiatric disorder.

Schizophrenia. It is highly unrealistic to expect 1 drug (such as a dopamine antagonist) to show efficacy for schizophrenia’s disparate symptoms, including positive symptoms, negative symptoms, cognitive impairment, mood dysregulation, and substance use. Yet antipsychotic monotherapy remains the standard of care in schizophrenia, and there are no FDA combination trials of antipsychotics. However, in the United States, more than one-third of persons with chronic schizophrenia receive ≥2 antipsychotics because their psychiatrist found that combinations exerted more efficacy compared with just 1 antipsychotic agent. A combination of 2 atypical antipsychotics may be superior to monotherapy, but controlled studies have not been conducted.

In addition, patients receiving clozapine for refractory schizophrenia experienced significant improvement with the addition of lamotrigine.⁶ Another anticonvulsant, valproate, also was shown to accelerate response to an antipsychotic.⁷ Clinical trials are being conducted for new agents that enhance memory⁸ and negative symptoms.⁹ If the results are positive, the future of schizophrenia pharmacotherapy will shift decisively to polytherapy of 3 or even 4 drugs targeting positive, negative, cognitive, and mood symptoms.¹⁰

Anxiety. Recent studies confirm the benefits of combining small doses of atypical antipsychotics to an antidepressant/anxiolytic regimen.¹¹ Most Patients with anxiety receive benzodiazepines as well.

OCD. Most patients with OCD do not achieve a remission with a selective serotonin reuptake inhibitor. Many studies have indicated additional improvement from adding an atypical antipsychotic.¹² Other studies have added the glutamate modulating agent memantine with reported benefit.

The writing is now on the psychopharmacology wall: Although many psychiatric patients achieve some response to a single agent, combination therapy often leads to higher remission rates, which is the foremost goal of pharmacotherapy. The negative connotation of polypharmacy will fade as combination therapies become the new standard of care rather than a reviled clinical practice.

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses:

Unipolar depression. Blier et al¹ demonstrated a remarkable superiority of 3 different combinations of 2 antidepressants compared with fluoxetine monotherapy. The remission rate with combination therapy (46% to 58%) was double that of fluoxetine alone (25%). When 1 of the 2 antidepressants was blindly discontinued in high responders, 40% relapsed. Tolerability to the combination was the same as to monotherapy. Recent FDA approval of 2 atypical antipsychotics—aripiprazole² and quetiapine³—as adjuncts to antidepressants to increase the remission rates further supports the case for combination therapy.

Bipolar disorder. Psychiatrists know that combining a mood stabilizer with an antipsychotic exerts more efficacy that either drug alone.⁴ But what about combining 2 mood stabilizers? A recent study⁵ confirmed the superiority of combining lithium plus valproate compared with either 1 alone. Score another victory for polypharmacy in bipolar disorder, where FDA studies of combination therapy are more common than in any other psychiatric disorder.

Schizophrenia. It is highly unrealistic to expect 1 drug (such as a dopamine antagonist) to show efficacy for schizophrenia’s disparate symptoms, including positive symptoms, negative symptoms, cognitive impairment, mood dysregulation, and substance use. Yet antipsychotic monotherapy remains the standard of care in schizophrenia, and there are no FDA combination trials of antipsychotics. However, in the United States, more than one-third of persons with chronic schizophrenia receive ≥2 antipsychotics because their psychiatrist found that combinations exerted more efficacy compared with just 1 antipsychotic agent. A combination of 2 atypical antipsychotics may be superior to monotherapy, but controlled studies have not been conducted.

In addition, patients receiving clozapine for refractory schizophrenia experienced significant improvement with the addition of lamotrigine.⁶ Another anticonvulsant, valproate, also was shown to accelerate response to an antipsychotic.⁷ Clinical trials are being conducted for new agents that enhance memory⁸ and negative symptoms.⁹ If the results are positive, the future of schizophrenia pharmacotherapy will shift decisively to polytherapy of 3 or even 4 drugs targeting positive, negative, cognitive, and mood symptoms.¹⁰

Anxiety. Recent studies confirm the benefits of combining small doses of atypical antipsychotics to an antidepressant/anxiolytic regimen.¹¹ Most Patients with anxiety receive benzodiazepines as well.

OCD. Most patients with OCD do not achieve a remission with a selective serotonin reuptake inhibitor. Many studies have indicated additional improvement from adding an atypical antipsychotic.¹² Other studies have added the glutamate modulating agent memantine with reported benefit.

The writing is now on the psychopharmacology wall: Although many psychiatric patients achieve some response to a single agent, combination therapy often leads to higher remission rates, which is the foremost goal of pharmacotherapy. The negative connotation of polypharmacy will fade as combination therapies become the new standard of care rather than a reviled clinical practice.

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses:

Unipolar depression. Blier et al¹ demonstrated a remarkable superiority of 3 different combinations of 2 antidepressants compared with fluoxetine monotherapy. The remission rate with combination therapy (46% to 58%) was double that of fluoxetine alone (25%). When 1 of the 2 antidepressants was blindly discontinued in high responders, 40% relapsed. Tolerability to the combination was the same as to monotherapy. Recent FDA approval of 2 atypical antipsychotics—aripiprazole² and quetiapine³—as adjuncts to antidepressants to increase the remission rates further supports the case for combination therapy.

Bipolar disorder. Psychiatrists know that combining a mood stabilizer with an antipsychotic exerts more efficacy that either drug alone.⁴ But what about combining 2 mood stabilizers? A recent study⁵ confirmed the superiority of combining lithium plus valproate compared with either 1 alone. Score another victory for polypharmacy in bipolar disorder, where FDA studies of combination therapy are more common than in any other psychiatric disorder.

Schizophrenia. It is highly unrealistic to expect 1 drug (such as a dopamine antagonist) to show efficacy for schizophrenia’s disparate symptoms, including positive symptoms, negative symptoms, cognitive impairment, mood dysregulation, and substance use. Yet antipsychotic monotherapy remains the standard of care in schizophrenia, and there are no FDA combination trials of antipsychotics. However, in the United States, more than one-third of persons with chronic schizophrenia receive ≥2 antipsychotics because their psychiatrist found that combinations exerted more efficacy compared with just 1 antipsychotic agent. A combination of 2 atypical antipsychotics may be superior to monotherapy, but controlled studies have not been conducted.

In addition, patients receiving clozapine for refractory schizophrenia experienced significant improvement with the addition of lamotrigine.⁶ Another anticonvulsant, valproate, also was shown to accelerate response to an antipsychotic.⁷ Clinical trials are being conducted for new agents that enhance memory⁸ and negative symptoms.⁹ If the results are positive, the future of schizophrenia pharmacotherapy will shift decisively to polytherapy of 3 or even 4 drugs targeting positive, negative, cognitive, and mood symptoms.¹⁰

Anxiety. Recent studies confirm the benefits of combining small doses of atypical antipsychotics to an antidepressant/anxiolytic regimen.¹¹ Most Patients with anxiety receive benzodiazepines as well.

OCD. Most patients with OCD do not achieve a remission with a selective serotonin reuptake inhibitor. Many studies have indicated additional improvement from adding an atypical antipsychotic.¹² Other studies have added the glutamate modulating agent memantine with reported benefit.

The writing is now on the psychopharmacology wall: Although many psychiatric patients achieve some response to a single agent, combination therapy often leads to higher remission rates, which is the foremost goal of pharmacotherapy. The negative connotation of polypharmacy will fade as combination therapies become the new standard of care rather than a reviled clinical practice.

Psychiatry is one of the most rapidly evolving medical disciplines. Its scientific foundation is neuroscience, which is growing at the most explosive pace in science. Yet the public and even other medical specialists still envision psychiatrists sitting behind a couch scribbling Freudian jargon on a yellow pad. For that reason, I propose that we create a manifesto that promulgates the basic tenets of psychiatry and make it a permanent, living document on CurrentPsychiatry.com.

So here I present my initial iteration of a psychiatric manifesto. I invite all readers and CurrentPsychiatry.com visitors to suggest valid additions and/or modifications. I will serve as the custodian and editor of the manifesto, in charge of its continuous update as a living document:

• Psychiatry is a medical specialty that focuses on brain disorders of behavior, thought, mood, cognition, and conation that are either primary, or secondary to general medical conditions or substance use.
• Psychiatric disorders are the product of complex interactions of genes and environmental factors, from the fetal stage throughout life.
• Psychiatric disorders are quite common, ranging from 25% to 50% of the population in various studies, and vary in severity from very mild to extremely severe and disabling.
• The complete assessment of psychiatric disorders almost always requires corroboration by a third party.
• A psychiatrist must be a fully trained physician who can integrate biologic, psychological, and social antecedents, make an accurate diagnosis, and administer pharmacologic/somatic and psychotherapeutic treatments to repair both brain and mind.
• As with all medical disciplines, the best outcome in psychiatry is full remission and recovery and the worst is mortality from suicide, homicide, self-neglect, comorbid medical illness, or iatrogenic causes.
• Social/vocational disability may be associated with some psychiatric disorders but most are not disabling. In addition, disability can remit but the mental health system penalizes recovery by withdrawing health care coverage.
• Psychiatric diagnoses have far more reliability than validity at this time. This discrepancy will be resolved as specific pathophysiologies of psychiatric disorders are elucidated.
• Severe psychiatric disorders with the potential for harm to self or others often require treatment against the will of the patient, whose insight into the illness and urgent need to receive treatment is seriously impaired. In contrast to their initial anger and resistance, involuntarily treated patients often are grateful after treatment.
• Current pharmacologic treatments of psychiatric disorders are based predominantly on serendipity rather than evidence-based neurobiologic mechanisms. However, the surge of genetic and neuroscience advances promises to lead to breakthroughs that will reshape treatment of psychiatric disorders.
• Although drug or neurostimulation treatments for psychiatric disorders are heavily regulated by the FDA and have specific indications based on large, placebo-controlled trials, psychosocial treatments are not. Extending regulatory approvals to psychotherapy may reduce the use of psychotherapeutic modalities not based on evidence.
• The public mental health system is broken and dysfunctional. Seriously mentally ill individuals are stigmatized and impoverished, lack primary medical care, die decades earlier than the life expectancy of the general population, often abuse alcohol and illicit drugs, and are incarcerated in such huge numbers that jails and prisons have transformed to the new mental “institutions.”
• The medical model is as appropriate for psychiatric disorders as it is for cancer and heart disease. However, political influences and the preponderance of nonphysicians in the mental health care system have shifted psychiatric treatment into a predominantly social model. This can be a disservice to psychiatric patients who do not receive any medical workup or treatment before diagnosis.
• Psychiatry has more detractors and self-appointed critics than any other medical specialty. This is the product of a malignant mix of ignorance and self-interest, especially by cults who offer their own scientifically untested “solutions” to mental illness (at a price, of course).
• The future of psychiatry is bright because it is intimately linked to neuroscience discoveries, which ultimately will delineate specific brain pathways underlying psychiatric nosology and treatment.

I invite readers to visit CurrentPsychiatry.com and suggest additions or modifications to this manifesto.

Psychiatry is one of the most rapidly evolving medical disciplines. Its scientific foundation is neuroscience, which is growing at the most explosive pace in science. Yet the public and even other medical specialists still envision psychiatrists sitting behind a couch scribbling Freudian jargon on a yellow pad. For that reason, I propose that we create a manifesto that promulgates the basic tenets of psychiatry and make it a permanent, living document on CurrentPsychiatry.com.

So here I present my initial iteration of a psychiatric manifesto. I invite all readers and CurrentPsychiatry.com visitors to suggest valid additions and/or modifications. I will serve as the custodian and editor of the manifesto, in charge of its continuous update as a living document:

• Psychiatry is a medical specialty that focuses on brain disorders of behavior, thought, mood, cognition, and conation that are either primary, or secondary to general medical conditions or substance use.
• Psychiatric disorders are the product of complex interactions of genes and environmental factors, from the fetal stage throughout life.
• Psychiatric disorders are quite common, ranging from 25% to 50% of the population in various studies, and vary in severity from very mild to extremely severe and disabling.
• The complete assessment of psychiatric disorders almost always requires corroboration by a third party.
• A psychiatrist must be a fully trained physician who can integrate biologic, psychological, and social antecedents, make an accurate diagnosis, and administer pharmacologic/somatic and psychotherapeutic treatments to repair both brain and mind.
• As with all medical disciplines, the best outcome in psychiatry is full remission and recovery and the worst is mortality from suicide, homicide, self-neglect, comorbid medical illness, or iatrogenic causes.
• Social/vocational disability may be associated with some psychiatric disorders but most are not disabling. In addition, disability can remit but the mental health system penalizes recovery by withdrawing health care coverage.
• Psychiatric diagnoses have far more reliability than validity at this time. This discrepancy will be resolved as specific pathophysiologies of psychiatric disorders are elucidated.
• Severe psychiatric disorders with the potential for harm to self or others often require treatment against the will of the patient, whose insight into the illness and urgent need to receive treatment is seriously impaired. In contrast to their initial anger and resistance, involuntarily treated patients often are grateful after treatment.
• Current pharmacologic treatments of psychiatric disorders are based predominantly on serendipity rather than evidence-based neurobiologic mechanisms. However, the surge of genetic and neuroscience advances promises to lead to breakthroughs that will reshape treatment of psychiatric disorders.
• Although drug or neurostimulation treatments for psychiatric disorders are heavily regulated by the FDA and have specific indications based on large, placebo-controlled trials, psychosocial treatments are not. Extending regulatory approvals to psychotherapy may reduce the use of psychotherapeutic modalities not based on evidence.
• The public mental health system is broken and dysfunctional. Seriously mentally ill individuals are stigmatized and impoverished, lack primary medical care, die decades earlier than the life expectancy of the general population, often abuse alcohol and illicit drugs, and are incarcerated in such huge numbers that jails and prisons have transformed to the new mental “institutions.”
• The medical model is as appropriate for psychiatric disorders as it is for cancer and heart disease. However, political influences and the preponderance of nonphysicians in the mental health care system have shifted psychiatric treatment into a predominantly social model. This can be a disservice to psychiatric patients who do not receive any medical workup or treatment before diagnosis.
• Psychiatry has more detractors and self-appointed critics than any other medical specialty. This is the product of a malignant mix of ignorance and self-interest, especially by cults who offer their own scientifically untested “solutions” to mental illness (at a price, of course).
• The future of psychiatry is bright because it is intimately linked to neuroscience discoveries, which ultimately will delineate specific brain pathways underlying psychiatric nosology and treatment.

I invite readers to visit CurrentPsychiatry.com and suggest additions or modifications to this manifesto.

Psychiatry is one of the most rapidly evolving medical disciplines. Its scientific foundation is neuroscience, which is growing at the most explosive pace in science. Yet the public and even other medical specialists still envision psychiatrists sitting behind a couch scribbling Freudian jargon on a yellow pad. For that reason, I propose that we create a manifesto that promulgates the basic tenets of psychiatry and make it a permanent, living document on CurrentPsychiatry.com.

So here I present my initial iteration of a psychiatric manifesto. I invite all readers and CurrentPsychiatry.com visitors to suggest valid additions and/or modifications. I will serve as the custodian and editor of the manifesto, in charge of its continuous update as a living document:

• Psychiatry is a medical specialty that focuses on brain disorders of behavior, thought, mood, cognition, and conation that are either primary, or secondary to general medical conditions or substance use.
• Psychiatric disorders are the product of complex interactions of genes and environmental factors, from the fetal stage throughout life.
• Psychiatric disorders are quite common, ranging from 25% to 50% of the population in various studies, and vary in severity from very mild to extremely severe and disabling.
• The complete assessment of psychiatric disorders almost always requires corroboration by a third party.
• A psychiatrist must be a fully trained physician who can integrate biologic, psychological, and social antecedents, make an accurate diagnosis, and administer pharmacologic/somatic and psychotherapeutic treatments to repair both brain and mind.
• As with all medical disciplines, the best outcome in psychiatry is full remission and recovery and the worst is mortality from suicide, homicide, self-neglect, comorbid medical illness, or iatrogenic causes.
• Social/vocational disability may be associated with some psychiatric disorders but most are not disabling. In addition, disability can remit but the mental health system penalizes recovery by withdrawing health care coverage.
• Psychiatric diagnoses have far more reliability than validity at this time. This discrepancy will be resolved as specific pathophysiologies of psychiatric disorders are elucidated.
• Severe psychiatric disorders with the potential for harm to self or others often require treatment against the will of the patient, whose insight into the illness and urgent need to receive treatment is seriously impaired. In contrast to their initial anger and resistance, involuntarily treated patients often are grateful after treatment.
• Current pharmacologic treatments of psychiatric disorders are based predominantly on serendipity rather than evidence-based neurobiologic mechanisms. However, the surge of genetic and neuroscience advances promises to lead to breakthroughs that will reshape treatment of psychiatric disorders.
• Although drug or neurostimulation treatments for psychiatric disorders are heavily regulated by the FDA and have specific indications based on large, placebo-controlled trials, psychosocial treatments are not. Extending regulatory approvals to psychotherapy may reduce the use of psychotherapeutic modalities not based on evidence.
• The public mental health system is broken and dysfunctional. Seriously mentally ill individuals are stigmatized and impoverished, lack primary medical care, die decades earlier than the life expectancy of the general population, often abuse alcohol and illicit drugs, and are incarcerated in such huge numbers that jails and prisons have transformed to the new mental “institutions.”
• The medical model is as appropriate for psychiatric disorders as it is for cancer and heart disease. However, political influences and the preponderance of nonphysicians in the mental health care system have shifted psychiatric treatment into a predominantly social model. This can be a disservice to psychiatric patients who do not receive any medical workup or treatment before diagnosis.
• Psychiatry has more detractors and self-appointed critics than any other medical specialty. This is the product of a malignant mix of ignorance and self-interest, especially by cults who offer their own scientifically untested “solutions” to mental illness (at a price, of course).
• The future of psychiatry is bright because it is intimately linked to neuroscience discoveries, which ultimately will delineate specific brain pathways underlying psychiatric nosology and treatment.

I invite readers to visit CurrentPsychiatry.com and suggest additions or modifications to this manifesto.

“Connecting the dots” has emerged as a buzzword in our media and popular culture. This expression is a picturesque way to denote competence and implies an uncanny ability to recognize and integrate what appear to be multiple unrelated data points into an important, actionable pattern. An incisive decision or intervention often follows.

When I hear this expression, I contemplate the centrality of connecting the dots in psychiatric practice. In fact, it is a ubiquitous and indispensable approach to diagnosing and treating our patients. Psychiatrists are trained to be highly skilled at connecting not only one set of dots, but often a bewildering array of complex and disparate sets of dots related to each patient we evaluate and manage. It is impossible to arrive at an accurate psychiatric diagnosis and construct an appropriate and comprehensive treatment plan without connecting countless overt and covert dots related to interconnected pathologies across a patient’s brain, mind, and body. As part of the assessment, psychiatrists often presage the existence of dots that are not yet on their clinical radar and inquire about them with the patient and multiple corroborative sources. That’s what a good psychiatric interview and history taking usually entails.

Painting a diagnostic profile

The effective pursuit of connecting clinically relevant biologic, psychological, and social clinically relevant “dots” is an elegant mix of the art and science of psychiatry. By integrating a vast universe of clinical “dots,” (like an astronomer recognizing a galaxy in star-studded sky) psychiatrists can then identify their patients’ emotional topography, cognitive architecture, behavioral landscape, and psychodynamic geology. This enables us to formulate the patient’s clinical disorder across a matrix of biopsychosocial domains and paint a mosaic of “dots” representing predisposing, precipitating, perpetuating, and protective factors underpinning the patient’s psychopathology and illness course.

The emerging diagnostic profile of a patient leads to the next task of connecting another universe of dots related to launching a multifaceted treatment plan. An enormous number of dots have to be connected to determine a safe and effective treatment consistent with the patient’s demographics, lifestyle, social background, attitudes, beliefs, past and current medical history, family history, comorbidities, and laboratory data. Once those dots are connected and treatment begins, another phase of connecting the dots follows to monitor efficacy, safety, tolerability, and various clinical and functional outcomes related to treatment. Unless this phase is done expertly and meticulously, a patient’s remission, recovery, and return to wellness may be elusive and relapse or complications may develop.

We psychiatrists perform the Herculean task of connecting the dots many times a day on a heterogeneous group of patients with various psychopathologies, and we appear to do it effortlessly. This is a gratifying testimonial to the extensive and arduous years of training it takes to become skillful psychiatric physicians.

We always assume that other professionals also are connecting dots effectively in their respective areas of responsibility. Failure to connect the dots could result in a minor setback, or, in some cases, a catastrophic event. Aristotle defined “virtue” as excelling in one’s job. When we do our job well—diagnosing and healing mental, emotional, and behavioral brain disorders, preventing harm to self and others, and restoring wellness to ailing individuals—we psychiatrists are accomplishing “virtuous” acts and thus earn the privilege to be called “virtuosos.”

“Connecting the dots” has emerged as a buzzword in our media and popular culture. This expression is a picturesque way to denote competence and implies an uncanny ability to recognize and integrate what appear to be multiple unrelated data points into an important, actionable pattern. An incisive decision or intervention often follows.

When I hear this expression, I contemplate the centrality of connecting the dots in psychiatric practice. In fact, it is a ubiquitous and indispensable approach to diagnosing and treating our patients. Psychiatrists are trained to be highly skilled at connecting not only one set of dots, but often a bewildering array of complex and disparate sets of dots related to each patient we evaluate and manage. It is impossible to arrive at an accurate psychiatric diagnosis and construct an appropriate and comprehensive treatment plan without connecting countless overt and covert dots related to interconnected pathologies across a patient’s brain, mind, and body. As part of the assessment, psychiatrists often presage the existence of dots that are not yet on their clinical radar and inquire about them with the patient and multiple corroborative sources. That’s what a good psychiatric interview and history taking usually entails.

Painting a diagnostic profile

The effective pursuit of connecting clinically relevant biologic, psychological, and social clinically relevant “dots” is an elegant mix of the art and science of psychiatry. By integrating a vast universe of clinical “dots,” (like an astronomer recognizing a galaxy in star-studded sky) psychiatrists can then identify their patients’ emotional topography, cognitive architecture, behavioral landscape, and psychodynamic geology. This enables us to formulate the patient’s clinical disorder across a matrix of biopsychosocial domains and paint a mosaic of “dots” representing predisposing, precipitating, perpetuating, and protective factors underpinning the patient’s psychopathology and illness course.

The emerging diagnostic profile of a patient leads to the next task of connecting another universe of dots related to launching a multifaceted treatment plan. An enormous number of dots have to be connected to determine a safe and effective treatment consistent with the patient’s demographics, lifestyle, social background, attitudes, beliefs, past and current medical history, family history, comorbidities, and laboratory data. Once those dots are connected and treatment begins, another phase of connecting the dots follows to monitor efficacy, safety, tolerability, and various clinical and functional outcomes related to treatment. Unless this phase is done expertly and meticulously, a patient’s remission, recovery, and return to wellness may be elusive and relapse or complications may develop.

We psychiatrists perform the Herculean task of connecting the dots many times a day on a heterogeneous group of patients with various psychopathologies, and we appear to do it effortlessly. This is a gratifying testimonial to the extensive and arduous years of training it takes to become skillful psychiatric physicians.

We always assume that other professionals also are connecting dots effectively in their respective areas of responsibility. Failure to connect the dots could result in a minor setback, or, in some cases, a catastrophic event. Aristotle defined “virtue” as excelling in one’s job. When we do our job well—diagnosing and healing mental, emotional, and behavioral brain disorders, preventing harm to self and others, and restoring wellness to ailing individuals—we psychiatrists are accomplishing “virtuous” acts and thus earn the privilege to be called “virtuosos.”

“Connecting the dots” has emerged as a buzzword in our media and popular culture. This expression is a picturesque way to denote competence and implies an uncanny ability to recognize and integrate what appear to be multiple unrelated data points into an important, actionable pattern. An incisive decision or intervention often follows.

When I hear this expression, I contemplate the centrality of connecting the dots in psychiatric practice. In fact, it is a ubiquitous and indispensable approach to diagnosing and treating our patients. Psychiatrists are trained to be highly skilled at connecting not only one set of dots, but often a bewildering array of complex and disparate sets of dots related to each patient we evaluate and manage. It is impossible to arrive at an accurate psychiatric diagnosis and construct an appropriate and comprehensive treatment plan without connecting countless overt and covert dots related to interconnected pathologies across a patient’s brain, mind, and body. As part of the assessment, psychiatrists often presage the existence of dots that are not yet on their clinical radar and inquire about them with the patient and multiple corroborative sources. That’s what a good psychiatric interview and history taking usually entails.

Painting a diagnostic profile

The effective pursuit of connecting clinically relevant biologic, psychological, and social clinically relevant “dots” is an elegant mix of the art and science of psychiatry. By integrating a vast universe of clinical “dots,” (like an astronomer recognizing a galaxy in star-studded sky) psychiatrists can then identify their patients’ emotional topography, cognitive architecture, behavioral landscape, and psychodynamic geology. This enables us to formulate the patient’s clinical disorder across a matrix of biopsychosocial domains and paint a mosaic of “dots” representing predisposing, precipitating, perpetuating, and protective factors underpinning the patient’s psychopathology and illness course.

The emerging diagnostic profile of a patient leads to the next task of connecting another universe of dots related to launching a multifaceted treatment plan. An enormous number of dots have to be connected to determine a safe and effective treatment consistent with the patient’s demographics, lifestyle, social background, attitudes, beliefs, past and current medical history, family history, comorbidities, and laboratory data. Once those dots are connected and treatment begins, another phase of connecting the dots follows to monitor efficacy, safety, tolerability, and various clinical and functional outcomes related to treatment. Unless this phase is done expertly and meticulously, a patient’s remission, recovery, and return to wellness may be elusive and relapse or complications may develop.

We psychiatrists perform the Herculean task of connecting the dots many times a day on a heterogeneous group of patients with various psychopathologies, and we appear to do it effortlessly. This is a gratifying testimonial to the extensive and arduous years of training it takes to become skillful psychiatric physicians.

We always assume that other professionals also are connecting dots effectively in their respective areas of responsibility. Failure to connect the dots could result in a minor setback, or, in some cases, a catastrophic event. Aristotle defined “virtue” as excelling in one’s job. When we do our job well—diagnosing and healing mental, emotional, and behavioral brain disorders, preventing harm to self and others, and restoring wellness to ailing individuals—we psychiatrists are accomplishing “virtuous” acts and thus earn the privilege to be called “virtuosos.”