Henry A. Nasrallah, MD

We all have patients with thick charts, the mentally ill individuals who push our clinical skills to the limit. They respond poorly to the entire algorithm of approved medications for depression, anxiety, or psychosis. Their symptoms hardly budge despite multiple psychotherapeutic interventions. They lead lives of quiet desperation and suffer through many hospitalizations and outpatient visits. They are perennially at high risk for harm to self or others. They get many side effects yet meager benefits from pharmacotherapy. Their social and vocational functions often are minimal to nil. Their life has little meaning beyond doleful patienthood.

Too complicated to be managed by primary care providers and most mental health practitioners, treatment-resistant patients often have several psychiatric comorbidities—both axis I and II. They frequently suffer from axis III disorders as well. Their lack of tangible response (let alone remission) frustrates us. Their poor treatment course and outcomes eventually tempt us to resort to unapproved polypharmacy and other non evidence-based practices in a desperate effort to help them.

We worry about our persistently unimproved patients; they haunt our thoughts after work. They are a constant reminder of how critical it is for our field to conduct aggressive, relentless research to unravel the underlying biology of chronic nonresponsive, disabling psychiatric brain disorders that rob children, adults, and elderly persons of their potential or even the ability to pursue happiness. We long for treatment breakthroughs that may reverse the downward spiral of their tortured lives.

Treatment resistance in my long-suffering patients incites me to ask important questions that beg for answers, such as:

• Are treatment-resistant patients afflicted by a categorically different subtype of illness, or do they suffer from a more severe form of the illness (ie, a dimensional difference)?
• Are some treatment-resistant patients victims of misdiagnosis? Do they have a psychiatric illness secondary to an unrecognized general medical condition that fails to respond to standard psychiatric treatments (such as a lack of response to several antidepressants in a patient with hypothyroid-induced depression or lack of efficacy of neuroleptics in psychosis secondary to a porphyria or Niemann-Pick disease)?
• Why isn’t the pharmaceutical industry conducting trials that target treatment-resistant patients? Controlled research trials in all clinical drug development programs for psychotropic medications explicitly exclude patients with a history of nonresponse. Thus, if a drug proves to be superior to placebo in FDA trials, it is likely to have efficacy in responsive patients but not in patients who have a history of nonresponse to prior medications
• Why are there no FDA studies of combination therapy—using drugs with different mechanisms of action—jointly sponsored (where necessary) by 2 or more pharmaceutical companies? Evidence-based, FDA -approved combinations are common for severe hypertension, diabetes, and cardiovascular disease; why not for severe psychiatric disorders?
• Why are personality disorders and psychiatric comorbidities more likely in treatment-resistant patients, and is this a neurobiologic clue for our nosologic/diagnostic framework and an impetus for better and innovative drug development?
• Why isn’t more funding from the National Institute of Mental Health targeting treatment-resistant diagnostic groups? Effective solutions for treatment-resistant populations, whose care often is very expensive, can be extremely beneficial for the affected individuals as well as substantially cost-effective for society at large.

Until my questions can be answered—and better treatment options emerge for my treatment-resistant patients—I will continue to do my best to relieve their agony and anguish. I will then write more progress notes and add yet more sheets of paper to their already thick charts.

We all have patients with thick charts, the mentally ill individuals who push our clinical skills to the limit. They respond poorly to the entire algorithm of approved medications for depression, anxiety, or psychosis. Their symptoms hardly budge despite multiple psychotherapeutic interventions. They lead lives of quiet desperation and suffer through many hospitalizations and outpatient visits. They are perennially at high risk for harm to self or others. They get many side effects yet meager benefits from pharmacotherapy. Their social and vocational functions often are minimal to nil. Their life has little meaning beyond doleful patienthood.

Too complicated to be managed by primary care providers and most mental health practitioners, treatment-resistant patients often have several psychiatric comorbidities—both axis I and II. They frequently suffer from axis III disorders as well. Their lack of tangible response (let alone remission) frustrates us. Their poor treatment course and outcomes eventually tempt us to resort to unapproved polypharmacy and other non evidence-based practices in a desperate effort to help them.

We worry about our persistently unimproved patients; they haunt our thoughts after work. They are a constant reminder of how critical it is for our field to conduct aggressive, relentless research to unravel the underlying biology of chronic nonresponsive, disabling psychiatric brain disorders that rob children, adults, and elderly persons of their potential or even the ability to pursue happiness. We long for treatment breakthroughs that may reverse the downward spiral of their tortured lives.

Treatment resistance in my long-suffering patients incites me to ask important questions that beg for answers, such as:

• Are treatment-resistant patients afflicted by a categorically different subtype of illness, or do they suffer from a more severe form of the illness (ie, a dimensional difference)?
• Are some treatment-resistant patients victims of misdiagnosis? Do they have a psychiatric illness secondary to an unrecognized general medical condition that fails to respond to standard psychiatric treatments (such as a lack of response to several antidepressants in a patient with hypothyroid-induced depression or lack of efficacy of neuroleptics in psychosis secondary to a porphyria or Niemann-Pick disease)?
• Why isn’t the pharmaceutical industry conducting trials that target treatment-resistant patients? Controlled research trials in all clinical drug development programs for psychotropic medications explicitly exclude patients with a history of nonresponse. Thus, if a drug proves to be superior to placebo in FDA trials, it is likely to have efficacy in responsive patients but not in patients who have a history of nonresponse to prior medications
• Why are there no FDA studies of combination therapy—using drugs with different mechanisms of action—jointly sponsored (where necessary) by 2 or more pharmaceutical companies? Evidence-based, FDA -approved combinations are common for severe hypertension, diabetes, and cardiovascular disease; why not for severe psychiatric disorders?
• Why are personality disorders and psychiatric comorbidities more likely in treatment-resistant patients, and is this a neurobiologic clue for our nosologic/diagnostic framework and an impetus for better and innovative drug development?
• Why isn’t more funding from the National Institute of Mental Health targeting treatment-resistant diagnostic groups? Effective solutions for treatment-resistant populations, whose care often is very expensive, can be extremely beneficial for the affected individuals as well as substantially cost-effective for society at large.

Until my questions can be answered—and better treatment options emerge for my treatment-resistant patients—I will continue to do my best to relieve their agony and anguish. I will then write more progress notes and add yet more sheets of paper to their already thick charts.

We all have patients with thick charts, the mentally ill individuals who push our clinical skills to the limit. They respond poorly to the entire algorithm of approved medications for depression, anxiety, or psychosis. Their symptoms hardly budge despite multiple psychotherapeutic interventions. They lead lives of quiet desperation and suffer through many hospitalizations and outpatient visits. They are perennially at high risk for harm to self or others. They get many side effects yet meager benefits from pharmacotherapy. Their social and vocational functions often are minimal to nil. Their life has little meaning beyond doleful patienthood.

Too complicated to be managed by primary care providers and most mental health practitioners, treatment-resistant patients often have several psychiatric comorbidities—both axis I and II. They frequently suffer from axis III disorders as well. Their lack of tangible response (let alone remission) frustrates us. Their poor treatment course and outcomes eventually tempt us to resort to unapproved polypharmacy and other non evidence-based practices in a desperate effort to help them.

We worry about our persistently unimproved patients; they haunt our thoughts after work. They are a constant reminder of how critical it is for our field to conduct aggressive, relentless research to unravel the underlying biology of chronic nonresponsive, disabling psychiatric brain disorders that rob children, adults, and elderly persons of their potential or even the ability to pursue happiness. We long for treatment breakthroughs that may reverse the downward spiral of their tortured lives.

Treatment resistance in my long-suffering patients incites me to ask important questions that beg for answers, such as:

• Are treatment-resistant patients afflicted by a categorically different subtype of illness, or do they suffer from a more severe form of the illness (ie, a dimensional difference)?
• Are some treatment-resistant patients victims of misdiagnosis? Do they have a psychiatric illness secondary to an unrecognized general medical condition that fails to respond to standard psychiatric treatments (such as a lack of response to several antidepressants in a patient with hypothyroid-induced depression or lack of efficacy of neuroleptics in psychosis secondary to a porphyria or Niemann-Pick disease)?
• Why isn’t the pharmaceutical industry conducting trials that target treatment-resistant patients? Controlled research trials in all clinical drug development programs for psychotropic medications explicitly exclude patients with a history of nonresponse. Thus, if a drug proves to be superior to placebo in FDA trials, it is likely to have efficacy in responsive patients but not in patients who have a history of nonresponse to prior medications
• Why are there no FDA studies of combination therapy—using drugs with different mechanisms of action—jointly sponsored (where necessary) by 2 or more pharmaceutical companies? Evidence-based, FDA -approved combinations are common for severe hypertension, diabetes, and cardiovascular disease; why not for severe psychiatric disorders?
• Why are personality disorders and psychiatric comorbidities more likely in treatment-resistant patients, and is this a neurobiologic clue for our nosologic/diagnostic framework and an impetus for better and innovative drug development?
• Why isn’t more funding from the National Institute of Mental Health targeting treatment-resistant diagnostic groups? Effective solutions for treatment-resistant populations, whose care often is very expensive, can be extremely beneficial for the affected individuals as well as substantially cost-effective for society at large.

Until my questions can be answered—and better treatment options emerge for my treatment-resistant patients—I will continue to do my best to relieve their agony and anguish. I will then write more progress notes and add yet more sheets of paper to their already thick charts.

A recent psychology journal article lambasted clinical psychologists for not using evidence-based psychotherapeutic modalities when treating their patients.¹ The authors pointed out that many psychologists were ignoring efficacious and cost-effective psychotherapy interventions or using approaches that lack sufficient evidence.

An accompanying editorial² was equally scathing—calling the disconnect between clinical psychology practice and advances in psychological science “an unconscionable embarrassment”—and warned that the profession “will increasingly discredit and marginalize itself” if it persists in neglecting evidence-based practices. The author quoted the respected late psychologist Paul Meehl as saying “most clinical psychologists select their methods like kids make choices in a candy store” and added that the comment is heart-breaking because it is true. A Newsweek column—“Ignoring the evidence: Why do psychologists reject science?”³—elicited little agreement and mostly howls of protest from psychologists.

So, are psychiatrists more evidence-based than psychologists? We manage patients who are more severely ill than those seen by psychologists, and we use both pharmacotherapy and psychotherapy to stabilize neurobiologic disorders. Because only 15% of DSM-IV-TR diagnostic categories have an evidence-based, FDA-approved drug treatment,⁴ we practice by necessity a substantial amount of non-evidenced-based (off-label) pharmacotherapy. But what about psychiatric conditions for which evidence-based treatments exist? Do studies show that we follow the evidence?

Psychiatrists’ track record

The Schizophrenia Patient Outcomes Research Team⁵ assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.

A study using data from the National Comorbidity Survey⁶ found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.

Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia⁷ showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.

Who is evidence-based: A self-assessment

Are YOU an evidence-based psychiatric clinician? Ask yourself:

• Can I correctly define evidence-based psychopharmacology?
• Do I regularly read systematic reviews (such as Cochrane reviews) or meta-analytic articles about the medications I prescribe?
• Can I cite at least 1 randomized controlled trial supporting my use of each medication I prescribe?
• Do I know what “effect size” means?
• Do I usually or sometimes select a psychotherapeutic agent based on number needed to treat (NNT) or number needed to harm (NNH)?
• Do I routinely use clinical rating scales employed in FDA controlled trials to quantify the severity of my patients’ illness and determine whether they achieve “remission” or just a “response”?

Psychiatric practice should be evidence-based and continuously adapt to incorporate the wealth of evidence being generated. Psychiatrists who do not keep up with the evidence run the risk of practicing psychopharmacology of the previous millennium.

A recent psychology journal article lambasted clinical psychologists for not using evidence-based psychotherapeutic modalities when treating their patients.¹ The authors pointed out that many psychologists were ignoring efficacious and cost-effective psychotherapy interventions or using approaches that lack sufficient evidence.

An accompanying editorial² was equally scathing—calling the disconnect between clinical psychology practice and advances in psychological science “an unconscionable embarrassment”—and warned that the profession “will increasingly discredit and marginalize itself” if it persists in neglecting evidence-based practices. The author quoted the respected late psychologist Paul Meehl as saying “most clinical psychologists select their methods like kids make choices in a candy store” and added that the comment is heart-breaking because it is true. A Newsweek column—“Ignoring the evidence: Why do psychologists reject science?”³—elicited little agreement and mostly howls of protest from psychologists.

So, are psychiatrists more evidence-based than psychologists? We manage patients who are more severely ill than those seen by psychologists, and we use both pharmacotherapy and psychotherapy to stabilize neurobiologic disorders. Because only 15% of DSM-IV-TR diagnostic categories have an evidence-based, FDA-approved drug treatment,⁴ we practice by necessity a substantial amount of non-evidenced-based (off-label) pharmacotherapy. But what about psychiatric conditions for which evidence-based treatments exist? Do studies show that we follow the evidence?

Psychiatrists’ track record

The Schizophrenia Patient Outcomes Research Team⁵ assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.

A study using data from the National Comorbidity Survey⁶ found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.

Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia⁷ showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.

Who is evidence-based: A self-assessment

Are YOU an evidence-based psychiatric clinician? Ask yourself:

• Can I correctly define evidence-based psychopharmacology?
• Do I regularly read systematic reviews (such as Cochrane reviews) or meta-analytic articles about the medications I prescribe?
• Can I cite at least 1 randomized controlled trial supporting my use of each medication I prescribe?
• Do I know what “effect size” means?
• Do I usually or sometimes select a psychotherapeutic agent based on number needed to treat (NNT) or number needed to harm (NNH)?
• Do I routinely use clinical rating scales employed in FDA controlled trials to quantify the severity of my patients’ illness and determine whether they achieve “remission” or just a “response”?

Psychiatric practice should be evidence-based and continuously adapt to incorporate the wealth of evidence being generated. Psychiatrists who do not keep up with the evidence run the risk of practicing psychopharmacology of the previous millennium.

A recent psychology journal article lambasted clinical psychologists for not using evidence-based psychotherapeutic modalities when treating their patients.¹ The authors pointed out that many psychologists were ignoring efficacious and cost-effective psychotherapy interventions or using approaches that lack sufficient evidence.

An accompanying editorial² was equally scathing—calling the disconnect between clinical psychology practice and advances in psychological science “an unconscionable embarrassment”—and warned that the profession “will increasingly discredit and marginalize itself” if it persists in neglecting evidence-based practices. The author quoted the respected late psychologist Paul Meehl as saying “most clinical psychologists select their methods like kids make choices in a candy store” and added that the comment is heart-breaking because it is true. A Newsweek column—“Ignoring the evidence: Why do psychologists reject science?”³—elicited little agreement and mostly howls of protest from psychologists.

So, are psychiatrists more evidence-based than psychologists? We manage patients who are more severely ill than those seen by psychologists, and we use both pharmacotherapy and psychotherapy to stabilize neurobiologic disorders. Because only 15% of DSM-IV-TR diagnostic categories have an evidence-based, FDA-approved drug treatment,⁴ we practice by necessity a substantial amount of non-evidenced-based (off-label) pharmacotherapy. But what about psychiatric conditions for which evidence-based treatments exist? Do studies show that we follow the evidence?

Psychiatrists’ track record

The Schizophrenia Patient Outcomes Research Team⁵ assessed how the treatment of 719 patients with schizophrenia conformed to 12 evidence-based treatment recommendations. Overall, <50% of treatments conformed to the recommendations, with higher conformance rates seen for rural than urban patients and for Caucasian patients than minorities.

A study using data from the National Comorbidity Survey⁶ found that only 40% of respondents with serious psychiatric disorders had received treatment in the previous 12 months, and only 15% received care considered at least minimally adequate. Four predictors of not receiving minimally adequate treatment included being a young adult or African-American, living in the South, suffering from a psychotic disorder, and being treated by physicians other than psychiatrists.

Finally, a recent survey of psychiatrists’ adherence to evidence-based antipsychotic treatment in schizophrenia⁷ showed: 1) mid-career psychiatrists more adherent than early or late-career counterparts; 2) male psychiatrists more adherent than female; 3) those carrying a large workload of schizophrenia patients more likely to adhere to scientific literature.

Who is evidence-based: A self-assessment

Are YOU an evidence-based psychiatric clinician? Ask yourself:

• Can I correctly define evidence-based psychopharmacology?
• Do I regularly read systematic reviews (such as Cochrane reviews) or meta-analytic articles about the medications I prescribe?
• Can I cite at least 1 randomized controlled trial supporting my use of each medication I prescribe?
• Do I know what “effect size” means?
• Do I usually or sometimes select a psychotherapeutic agent based on number needed to treat (NNT) or number needed to harm (NNH)?
• Do I routinely use clinical rating scales employed in FDA controlled trials to quantify the severity of my patients’ illness and determine whether they achieve “remission” or just a “response”?

Psychiatric practice should be evidence-based and continuously adapt to incorporate the wealth of evidence being generated. Psychiatrists who do not keep up with the evidence run the risk of practicing psychopharmacology of the previous millennium.

Like everyone else, I could not avoid being swept up by the national debate about how to reform our health care system. The debate has been highly politicized, with the liberal left strongly supporting and the conservative right vehemently opposing a single-payer government-run public option (but keeping Medicare and Medicaid). Independents seem to waver between the major overhaul of a public option and making the system more competitive and less expensive.

Developing an idea

Recently I was speaking to psychiatry colleagues in the United Kingdom as their National Health Service (NHS) celebrated its 60th anniversary. Some raved about the NHS, others damned it with faint praise, and a few were scathingly critical. One psychiatrist said her father developed a brain tumor and was placed on a waiting list of several weeks before surgery would be performed. She paid a private neurosurgeon several thousand pounds to remove his tumor and save his life! She says this happens often, and only the wealthy can afford to bypass the NHS for prompt medical care.

Later, I was lecturing to psychiatrists in Canada and decided to poll them about their government-run national health service. I asked my audience to raise their hands if they believed their health care system is working well and if they would encourage the United States to adopt a similar model. Ninety percent raised their hands!

So I started thinking: where do U.S. psychiatrists stand on a public health care option? I decided to formulate a hypothesis and test it by polling a sample of Current Psychiatry readers. My hypothesis : A substantial proportion (>60%) of practicing U.S. psychiatrists favor a single-payer public option. My rationale: My hunch was that what we psychiatrists deal with in clinical practice may shape and predict how we think about health care, irrespective of our politics. For example:

• Empathy and caring about our patients are basic tenets of psychiatric practice.
• Many of our patients are uninsured, underinsured, or belong to a government-run health plan.
• Chronic psychiatric patients tend to be indigent or poor and can barely afford to see a health care provider, were it not for government programs designed to help them.
• Psychiatrists are trained to work in teams including other mental health disciplines, and many of us work in community settings. In some ways, we are “community organizers” for our patients.
• Psychiatrists are passionately opposed to discrimination based on age, gender, race, religion, or sexual orientation. We serve as advocates for our patients who are “disabled” and depend on the government for food, shelter, and medical care.
• Psychiatrists are keenly aware of the importance of a “social placenta” to help nurture our patients and provide for their personal, social, vocational, and health needs.
• Psychiatrists believe in individual responsibility but in sharing the burden when an individual cannot cope because of biological, psychological, or social reasons.
• Psychiatrists suffer along with our patients. The stigma of mental illness is social and economic. Even so-called “good insurance” rarely offers parity for psychiatric disorders, leaving patients with high co-payments, ridiculous annual and lifetime caps, and arbitrary limits on hospital stays and outpatient visits.

Poll results. I wrote this editorial before I learned the results of an online poll of 5,000 Current Psychiatry readers conducted from September 24 to October 7, 2009 (320 responses [6% response rate]). To the statement, “If you could reform the nation’s health care system, you would favor a single government-run system to cover every American,” the responses were as follows:

• 32.5% for “strongly agree”
• 23.4% for “agree”
• 17.2% for “disagree”
• 26.9% for “strongly disagree.”

Thus, my hypothesis was confirmed by this poll but by a smaller margin than I predicted (56% of respondents favored a single-payer public option, instead of >60%). These colleagues sent in many insightful comments—agreeing and disagreeing—which you can read by clicking here.

It appears that politics may be more potent in shaping psychiatrists’ attitudes about the government’s role in health care than I postulated. I would be happy to hear your thoughts.

Like everyone else, I could not avoid being swept up by the national debate about how to reform our health care system. The debate has been highly politicized, with the liberal left strongly supporting and the conservative right vehemently opposing a single-payer government-run public option (but keeping Medicare and Medicaid). Independents seem to waver between the major overhaul of a public option and making the system more competitive and less expensive.

Developing an idea

Recently I was speaking to psychiatry colleagues in the United Kingdom as their National Health Service (NHS) celebrated its 60th anniversary. Some raved about the NHS, others damned it with faint praise, and a few were scathingly critical. One psychiatrist said her father developed a brain tumor and was placed on a waiting list of several weeks before surgery would be performed. She paid a private neurosurgeon several thousand pounds to remove his tumor and save his life! She says this happens often, and only the wealthy can afford to bypass the NHS for prompt medical care.

Later, I was lecturing to psychiatrists in Canada and decided to poll them about their government-run national health service. I asked my audience to raise their hands if they believed their health care system is working well and if they would encourage the United States to adopt a similar model. Ninety percent raised their hands!

So I started thinking: where do U.S. psychiatrists stand on a public health care option? I decided to formulate a hypothesis and test it by polling a sample of Current Psychiatry readers. My hypothesis : A substantial proportion (>60%) of practicing U.S. psychiatrists favor a single-payer public option. My rationale: My hunch was that what we psychiatrists deal with in clinical practice may shape and predict how we think about health care, irrespective of our politics. For example:

• Empathy and caring about our patients are basic tenets of psychiatric practice.
• Many of our patients are uninsured, underinsured, or belong to a government-run health plan.
• Chronic psychiatric patients tend to be indigent or poor and can barely afford to see a health care provider, were it not for government programs designed to help them.
• Psychiatrists are trained to work in teams including other mental health disciplines, and many of us work in community settings. In some ways, we are “community organizers” for our patients.
• Psychiatrists are passionately opposed to discrimination based on age, gender, race, religion, or sexual orientation. We serve as advocates for our patients who are “disabled” and depend on the government for food, shelter, and medical care.
• Psychiatrists are keenly aware of the importance of a “social placenta” to help nurture our patients and provide for their personal, social, vocational, and health needs.
• Psychiatrists believe in individual responsibility but in sharing the burden when an individual cannot cope because of biological, psychological, or social reasons.
• Psychiatrists suffer along with our patients. The stigma of mental illness is social and economic. Even so-called “good insurance” rarely offers parity for psychiatric disorders, leaving patients with high co-payments, ridiculous annual and lifetime caps, and arbitrary limits on hospital stays and outpatient visits.

Poll results. I wrote this editorial before I learned the results of an online poll of 5,000 Current Psychiatry readers conducted from September 24 to October 7, 2009 (320 responses [6% response rate]). To the statement, “If you could reform the nation’s health care system, you would favor a single government-run system to cover every American,” the responses were as follows:

• 32.5% for “strongly agree”
• 23.4% for “agree”
• 17.2% for “disagree”
• 26.9% for “strongly disagree.”

Thus, my hypothesis was confirmed by this poll but by a smaller margin than I predicted (56% of respondents favored a single-payer public option, instead of >60%). These colleagues sent in many insightful comments—agreeing and disagreeing—which you can read by clicking here.

It appears that politics may be more potent in shaping psychiatrists’ attitudes about the government’s role in health care than I postulated. I would be happy to hear your thoughts.

Like everyone else, I could not avoid being swept up by the national debate about how to reform our health care system. The debate has been highly politicized, with the liberal left strongly supporting and the conservative right vehemently opposing a single-payer government-run public option (but keeping Medicare and Medicaid). Independents seem to waver between the major overhaul of a public option and making the system more competitive and less expensive.

Developing an idea

Recently I was speaking to psychiatry colleagues in the United Kingdom as their National Health Service (NHS) celebrated its 60th anniversary. Some raved about the NHS, others damned it with faint praise, and a few were scathingly critical. One psychiatrist said her father developed a brain tumor and was placed on a waiting list of several weeks before surgery would be performed. She paid a private neurosurgeon several thousand pounds to remove his tumor and save his life! She says this happens often, and only the wealthy can afford to bypass the NHS for prompt medical care.

Later, I was lecturing to psychiatrists in Canada and decided to poll them about their government-run national health service. I asked my audience to raise their hands if they believed their health care system is working well and if they would encourage the United States to adopt a similar model. Ninety percent raised their hands!

So I started thinking: where do U.S. psychiatrists stand on a public health care option? I decided to formulate a hypothesis and test it by polling a sample of Current Psychiatry readers. My hypothesis : A substantial proportion (>60%) of practicing U.S. psychiatrists favor a single-payer public option. My rationale: My hunch was that what we psychiatrists deal with in clinical practice may shape and predict how we think about health care, irrespective of our politics. For example:

• Empathy and caring about our patients are basic tenets of psychiatric practice.
• Many of our patients are uninsured, underinsured, or belong to a government-run health plan.
• Chronic psychiatric patients tend to be indigent or poor and can barely afford to see a health care provider, were it not for government programs designed to help them.
• Psychiatrists are trained to work in teams including other mental health disciplines, and many of us work in community settings. In some ways, we are “community organizers” for our patients.
• Psychiatrists are passionately opposed to discrimination based on age, gender, race, religion, or sexual orientation. We serve as advocates for our patients who are “disabled” and depend on the government for food, shelter, and medical care.
• Psychiatrists are keenly aware of the importance of a “social placenta” to help nurture our patients and provide for their personal, social, vocational, and health needs.
• Psychiatrists believe in individual responsibility but in sharing the burden when an individual cannot cope because of biological, psychological, or social reasons.
• Psychiatrists suffer along with our patients. The stigma of mental illness is social and economic. Even so-called “good insurance” rarely offers parity for psychiatric disorders, leaving patients with high co-payments, ridiculous annual and lifetime caps, and arbitrary limits on hospital stays and outpatient visits.

Poll results. I wrote this editorial before I learned the results of an online poll of 5,000 Current Psychiatry readers conducted from September 24 to October 7, 2009 (320 responses [6% response rate]). To the statement, “If you could reform the nation’s health care system, you would favor a single government-run system to cover every American,” the responses were as follows:

• 32.5% for “strongly agree”
• 23.4% for “agree”
• 17.2% for “disagree”
• 26.9% for “strongly disagree.”

Thus, my hypothesis was confirmed by this poll but by a smaller margin than I predicted (56% of respondents favored a single-payer public option, instead of >60%). These colleagues sent in many insightful comments—agreeing and disagreeing—which you can read by clicking here.

It appears that politics may be more potent in shaping psychiatrists’ attitudes about the government’s role in health care than I postulated. I would be happy to hear your thoughts.

At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”

That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.

Medical specialties develop different skills

Consider the training consequences of other medical specialties: surgeons become adept at navigating structural anatomy with superb dexterity to extricate lesions, repair wounds, or transplant organs; radiologists excel at scanning complex black and white patterns in radiographic images to detect the subtlest pathologies or anomalies; pathologists pinpoint cause of death with autopsies and elegant tissue examinations; and obstetricians become virtuosos of birthing or repairing intricate reproductive structures.

We psychiatrists go well beyond the standard medical history, physical exam, and laboratory findings. Our major skills are detecting gross and minute deviations in the mental status exam and the range and nuances of patients’ behaviors, insight, judgment, cognition, coping skills, internal conflicts, drives, compulsions, thought processes, personality traits, decision-making, resilience, social skills, interpersonal adroitness, truthfulness, emotiveness, impulsivity, ambition, perceptions, perceptiveness, verbal and nonverbal communications, defense mechanisms, and outlook on life.

We also integrate our complex observations and findings with the rich collage of each patient’s unique cultural, religious, and educational background. We strive to find hidden or higher meaning in patients’ symptoms, words, and actions. We assess their potential lethality toward themselves or others and examine the often tortuous course of their existence. And, unlike other physicians, we observe their transference toward us and simultaneously examine our own conscious or subconscious countertransference—channeled via thoughts, emotions, and behavior—and we scrutinize potential or real boundary violations by patients and ourselves and act judiciously. No other specialty has as wide or deep a view as psychiatry of the totality of people’s lives.

Neurobiology of wisdom

The wonder of psychiatric practice is that we somehow navigate each patient’s unique jungle of thoughts, emotions, behaviors, and cognitions and skillfully weave a biopsychosocial diagnosis and treatment plan. By doing so, we develop different regions or circuits in our brains than surgeons, radiologists, or internists do. Meeks and Jeste’s wonderful article about the neurobiology of wisdom suggests that psychiatrists’ brains probably develop “wisdom circuitry” via advanced neuroplastic connectivity in the:

• prefrontal cortex (for emotional regulation, decision-making, and value relativism)
• lateral prefrontal cortex (to facilitate calculated reason-based decision-making)
• medial prefrontal cortex (for emotional valence and prosocial attitudes and behavior).¹

Is it possible that just as the finger-related motor cortex grows in pianists’ brains, psychiatrists’ prefrontal pathways undergo hypertrophy as we repeatedly assess and integrate mental observations, conceptualize a diagnosis, develop a strategic treatment plan, then counsel patient after patient on how to deal with stressors and develop more adaptive living skills and attitudes? Could those well-developed pathways enhance good judgment, decision-making, insightfulness, and wisdom?

Perhaps our medical/surgical colleagues consult with us because they have noted our ability—although by no means perfect—to assess and manage conflicting or ambiguous situations and develop wise solutions for the knotty and often painful human condition. However, they also should know that, human as we are, developing wisdom does not immunize us from making unwise decisions now and then.

At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”

That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.

Medical specialties develop different skills

Consider the training consequences of other medical specialties: surgeons become adept at navigating structural anatomy with superb dexterity to extricate lesions, repair wounds, or transplant organs; radiologists excel at scanning complex black and white patterns in radiographic images to detect the subtlest pathologies or anomalies; pathologists pinpoint cause of death with autopsies and elegant tissue examinations; and obstetricians become virtuosos of birthing or repairing intricate reproductive structures.

We psychiatrists go well beyond the standard medical history, physical exam, and laboratory findings. Our major skills are detecting gross and minute deviations in the mental status exam and the range and nuances of patients’ behaviors, insight, judgment, cognition, coping skills, internal conflicts, drives, compulsions, thought processes, personality traits, decision-making, resilience, social skills, interpersonal adroitness, truthfulness, emotiveness, impulsivity, ambition, perceptions, perceptiveness, verbal and nonverbal communications, defense mechanisms, and outlook on life.

We also integrate our complex observations and findings with the rich collage of each patient’s unique cultural, religious, and educational background. We strive to find hidden or higher meaning in patients’ symptoms, words, and actions. We assess their potential lethality toward themselves or others and examine the often tortuous course of their existence. And, unlike other physicians, we observe their transference toward us and simultaneously examine our own conscious or subconscious countertransference—channeled via thoughts, emotions, and behavior—and we scrutinize potential or real boundary violations by patients and ourselves and act judiciously. No other specialty has as wide or deep a view as psychiatry of the totality of people’s lives.

Neurobiology of wisdom

The wonder of psychiatric practice is that we somehow navigate each patient’s unique jungle of thoughts, emotions, behaviors, and cognitions and skillfully weave a biopsychosocial diagnosis and treatment plan. By doing so, we develop different regions or circuits in our brains than surgeons, radiologists, or internists do. Meeks and Jeste’s wonderful article about the neurobiology of wisdom suggests that psychiatrists’ brains probably develop “wisdom circuitry” via advanced neuroplastic connectivity in the:

• prefrontal cortex (for emotional regulation, decision-making, and value relativism)
• lateral prefrontal cortex (to facilitate calculated reason-based decision-making)
• medial prefrontal cortex (for emotional valence and prosocial attitudes and behavior).¹

Is it possible that just as the finger-related motor cortex grows in pianists’ brains, psychiatrists’ prefrontal pathways undergo hypertrophy as we repeatedly assess and integrate mental observations, conceptualize a diagnosis, develop a strategic treatment plan, then counsel patient after patient on how to deal with stressors and develop more adaptive living skills and attitudes? Could those well-developed pathways enhance good judgment, decision-making, insightfulness, and wisdom?

Perhaps our medical/surgical colleagues consult with us because they have noted our ability—although by no means perfect—to assess and manage conflicting or ambiguous situations and develop wise solutions for the knotty and often painful human condition. However, they also should know that, human as we are, developing wisdom does not immunize us from making unwise decisions now and then.

At a recent morning rounds, a resident presented a case of a do-not-resuscitate decision for an elderly patient, which our psychiatry consultation service received overnight from an internal medicine ward. Another resident casually mentioned how physicians from other services at our hospital habitually call on psychiatrists to “make the difficult ethical decisions for them.”

That got me thinking. Psychiatrists are expected to analyze conflicts, resolve dilemmas, exercise good judgment, provide advice to colleagues and patients, and display a transcendent and objective perspective about the complexities of life. Psychiatric training and practice prompt us to be thoughtful, tolerant of ambiguity, and willing to tackle the multilayered meanings and consequences of human behavior. Indeed, developing attributes related to the most advanced functions of the human mind is at the core of our professional training and clinical practice.

Medical specialties develop different skills

Consider the training consequences of other medical specialties: surgeons become adept at navigating structural anatomy with superb dexterity to extricate lesions, repair wounds, or transplant organs; radiologists excel at scanning complex black and white patterns in radiographic images to detect the subtlest pathologies or anomalies; pathologists pinpoint cause of death with autopsies and elegant tissue examinations; and obstetricians become virtuosos of birthing or repairing intricate reproductive structures.

We psychiatrists go well beyond the standard medical history, physical exam, and laboratory findings. Our major skills are detecting gross and minute deviations in the mental status exam and the range and nuances of patients’ behaviors, insight, judgment, cognition, coping skills, internal conflicts, drives, compulsions, thought processes, personality traits, decision-making, resilience, social skills, interpersonal adroitness, truthfulness, emotiveness, impulsivity, ambition, perceptions, perceptiveness, verbal and nonverbal communications, defense mechanisms, and outlook on life.

We also integrate our complex observations and findings with the rich collage of each patient’s unique cultural, religious, and educational background. We strive to find hidden or higher meaning in patients’ symptoms, words, and actions. We assess their potential lethality toward themselves or others and examine the often tortuous course of their existence. And, unlike other physicians, we observe their transference toward us and simultaneously examine our own conscious or subconscious countertransference—channeled via thoughts, emotions, and behavior—and we scrutinize potential or real boundary violations by patients and ourselves and act judiciously. No other specialty has as wide or deep a view as psychiatry of the totality of people’s lives.

Neurobiology of wisdom

The wonder of psychiatric practice is that we somehow navigate each patient’s unique jungle of thoughts, emotions, behaviors, and cognitions and skillfully weave a biopsychosocial diagnosis and treatment plan. By doing so, we develop different regions or circuits in our brains than surgeons, radiologists, or internists do. Meeks and Jeste’s wonderful article about the neurobiology of wisdom suggests that psychiatrists’ brains probably develop “wisdom circuitry” via advanced neuroplastic connectivity in the:

• prefrontal cortex (for emotional regulation, decision-making, and value relativism)
• lateral prefrontal cortex (to facilitate calculated reason-based decision-making)
• medial prefrontal cortex (for emotional valence and prosocial attitudes and behavior).¹

Is it possible that just as the finger-related motor cortex grows in pianists’ brains, psychiatrists’ prefrontal pathways undergo hypertrophy as we repeatedly assess and integrate mental observations, conceptualize a diagnosis, develop a strategic treatment plan, then counsel patient after patient on how to deal with stressors and develop more adaptive living skills and attitudes? Could those well-developed pathways enhance good judgment, decision-making, insightfulness, and wisdom?

Perhaps our medical/surgical colleagues consult with us because they have noted our ability—although by no means perfect—to assess and manage conflicting or ambiguous situations and develop wise solutions for the knotty and often painful human condition. However, they also should know that, human as we are, developing wisdom does not immunize us from making unwise decisions now and then.

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions,¹ paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Old paradigm: Clozapine is ‘last resort’

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried.² However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

In the 1990s, several more-tolerable second-generation antipsychotics (SGAs) modeled after the clozapine receptor-binding paradigm with “broader efficacy” were launched and quickly became the standard of care. Then in 2000, the field was jolted by a meta-analysis claiming that SGAs are not superior to FGAs in either efficacy or tolerability.³ The 5-year Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, completed in 2004, confirmed that FGA and SGA discontinuation rates were not different,⁴ but it also showed that clozapine’s superior efficacy to FGAs also extended to SGAs.

Emerging research into neuroplasticity and neurogenesis later indicated that SGAs are neuroprotective, whereas FGAs are not.⁵ As a class, SGAs appeared to have repaired their tarnished image but still suffered from the fact that several are associated with metabolic syndrome risk factors,⁶ which are linked to early mortality.

New paradigm: Clozapine should be ‘first-line’

Then a report by Ray et al⁷ showing a significant increase in sudden cardiac death associated with both FGAs and SGAs appeared in January 2009. This put all antipsychotics in a negative light again. But in July 2009, a massive 11-year study by Tiihonen et al⁸ of 66,881 schizophrenia patients in Finland introduced yet another paradigm shift. It strongly suggested that clozapine was the safest antipsychotic, with the lowest mortality from all causes compared with any FGA or SGA, and that it should be considered as first-line treatment! That study also reported that mortality in antipsychotic-treated patients was lower than in untreated ones, which neutralized the cardiac death findings of Ray et al.

The greatest paradigm shift from the Tiihonen et al⁸ study is the stunning conclusion that clozapine should be a first-line antipsychotic, not a last resort for refractory patients. Clozapine has not only the highest efficacy (a very important outcome measure) but also the lowest mortality (death is the most important outcome measure in medicine!). Not a single practice guideline has ever recommended clozapine as a first-line antipsychotic. It is puzzling why the obesity, hyperglycemia, and hyperlipidemia observed with clozapine do not increase mortality. The low suicide rate with clozapine is not surprising, however, because clozapine received FDA approval for the treatment of suicidality in schizophrenia based on the InterSePT study.⁹

The bottom line: Evidence-based research leads to paradigm shifts in treatment that can shatter clinical dogmas. Stay tuned; ongoing psychiatric research will certainly generate new paradigms, and our patients will be better for it.

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions,¹ paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Old paradigm: Clozapine is ‘last resort’

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried.² However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

In the 1990s, several more-tolerable second-generation antipsychotics (SGAs) modeled after the clozapine receptor-binding paradigm with “broader efficacy” were launched and quickly became the standard of care. Then in 2000, the field was jolted by a meta-analysis claiming that SGAs are not superior to FGAs in either efficacy or tolerability.³ The 5-year Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, completed in 2004, confirmed that FGA and SGA discontinuation rates were not different,⁴ but it also showed that clozapine’s superior efficacy to FGAs also extended to SGAs.

Emerging research into neuroplasticity and neurogenesis later indicated that SGAs are neuroprotective, whereas FGAs are not.⁵ As a class, SGAs appeared to have repaired their tarnished image but still suffered from the fact that several are associated with metabolic syndrome risk factors,⁶ which are linked to early mortality.

New paradigm: Clozapine should be ‘first-line’

Then a report by Ray et al⁷ showing a significant increase in sudden cardiac death associated with both FGAs and SGAs appeared in January 2009. This put all antipsychotics in a negative light again. But in July 2009, a massive 11-year study by Tiihonen et al⁸ of 66,881 schizophrenia patients in Finland introduced yet another paradigm shift. It strongly suggested that clozapine was the safest antipsychotic, with the lowest mortality from all causes compared with any FGA or SGA, and that it should be considered as first-line treatment! That study also reported that mortality in antipsychotic-treated patients was lower than in untreated ones, which neutralized the cardiac death findings of Ray et al.

The greatest paradigm shift from the Tiihonen et al⁸ study is the stunning conclusion that clozapine should be a first-line antipsychotic, not a last resort for refractory patients. Clozapine has not only the highest efficacy (a very important outcome measure) but also the lowest mortality (death is the most important outcome measure in medicine!). Not a single practice guideline has ever recommended clozapine as a first-line antipsychotic. It is puzzling why the obesity, hyperglycemia, and hyperlipidemia observed with clozapine do not increase mortality. The low suicide rate with clozapine is not surprising, however, because clozapine received FDA approval for the treatment of suicidality in schizophrenia based on the InterSePT study.⁹

The bottom line: Evidence-based research leads to paradigm shifts in treatment that can shatter clinical dogmas. Stay tuned; ongoing psychiatric research will certainly generate new paradigms, and our patients will be better for it.

Like the “paradigm shift” Thomas Kuhn coined in his seminal book, The Structure of Scientific Revolutions,¹ paradigm shifts have been occurring at a breathless pace in psychiatry. Thanks to ongoing research, changes in the clinical standard of care for schizophrenia in the past 20 years are a case in point.

Old paradigm: Clozapine is ‘last resort’

Let’s take 1988 as a starting point. That’s when clozapine was “resurrected” as the only drug with proven efficacy in refractory schizophrenia after several first-generation antipsychotics (FGAs) had been tried.² However, because of its potentially fatal side effect (agranulocytosis), clozapine was designated as an absolute last-resort agent. It also was stigmatized for its many other side effects, including serious metabolic complications.

In the 1990s, several more-tolerable second-generation antipsychotics (SGAs) modeled after the clozapine receptor-binding paradigm with “broader efficacy” were launched and quickly became the standard of care. Then in 2000, the field was jolted by a meta-analysis claiming that SGAs are not superior to FGAs in either efficacy or tolerability.³ The 5-year Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, completed in 2004, confirmed that FGA and SGA discontinuation rates were not different,⁴ but it also showed that clozapine’s superior efficacy to FGAs also extended to SGAs.

Emerging research into neuroplasticity and neurogenesis later indicated that SGAs are neuroprotective, whereas FGAs are not.⁵ As a class, SGAs appeared to have repaired their tarnished image but still suffered from the fact that several are associated with metabolic syndrome risk factors,⁶ which are linked to early mortality.

New paradigm: Clozapine should be ‘first-line’

Then a report by Ray et al⁷ showing a significant increase in sudden cardiac death associated with both FGAs and SGAs appeared in January 2009. This put all antipsychotics in a negative light again. But in July 2009, a massive 11-year study by Tiihonen et al⁸ of 66,881 schizophrenia patients in Finland introduced yet another paradigm shift. It strongly suggested that clozapine was the safest antipsychotic, with the lowest mortality from all causes compared with any FGA or SGA, and that it should be considered as first-line treatment! That study also reported that mortality in antipsychotic-treated patients was lower than in untreated ones, which neutralized the cardiac death findings of Ray et al.

The greatest paradigm shift from the Tiihonen et al⁸ study is the stunning conclusion that clozapine should be a first-line antipsychotic, not a last resort for refractory patients. Clozapine has not only the highest efficacy (a very important outcome measure) but also the lowest mortality (death is the most important outcome measure in medicine!). Not a single practice guideline has ever recommended clozapine as a first-line antipsychotic. It is puzzling why the obesity, hyperglycemia, and hyperlipidemia observed with clozapine do not increase mortality. The low suicide rate with clozapine is not surprising, however, because clozapine received FDA approval for the treatment of suicidality in schizophrenia based on the InterSePT study.⁹

The bottom line: Evidence-based research leads to paradigm shifts in treatment that can shatter clinical dogmas. Stay tuned; ongoing psychiatric research will certainly generate new paradigms, and our patients will be better for it.

Every psychiatrist and mental health professional encourages patients to “express your feelings.” Venting produces a cathartic effect, especially if frustrations have been harbored for a while. So I thought I should practice what I preach and tell you some things that annoy me about the contemporary state of psychiatry, which might bother some of you as well.

• Why have we allowed our patients to be relocated from hospitals to jails and prisons? How were the mentally ill transformed from “patients” to “felons?” State hospitals have been shuttered, but correctional facilities are a growth industry.
• Why have community-based mentally ill patients become “clients,” as if mental healthcare was a business transaction? Would cardiologists or oncologists accept labeling their patients as “clients?” No chance!
• Why did psychiatrists shed their white coats and psychiatric nurses replace their professional uniforms with street clothes? Medical attire used to serve as an important environmental cue that an inpatient ward was a “therapeutic facility.” Nowadays, hospitalized psychotic and bipolar patients think they are in a hotel (or, as one of my psychotic patients said recently, in a spaceship).
• Why is it that the more powerful the evidence that mental illnesses are brain disorders with neurobiological roots, the more “demedicalized” the community mental health system has become?
• Why don’t practitioners actively support research when they know that every treatment in clinical practice today was once a research project? The breakthrough treatments of tomorrow are being researched today. One simple way clinicians can help accelerate treatment discoveries is to refer patients to therapeutic clinical trials at local academic institutions.
• When are we going to overcome bureaucratic obstacles and give our public sector seriously mentally ill patients the continuity of care they need and deserve? Changing psychiatrists frequently puts patients at risk for diagnostic and treatment errors, repeated mistakes, and difficulties building rapport and therapeutic alliances.
• Why aren’t more psychiatrists collaborating actively with primary care providers? Up to 50% of chronically mentally ill individuals have serious medical conditions,¹ and up to 50% of primary care patients have mental health problems.² We desperately need an integrated, collaborative approach to mind-body illnesses.
• Why have psychiatrists in community mental health settings been reduced to writing prescriptions and doing “med checks” during sessions too brief to allow for the optimal approach of integrating psychotherapy with psychopharmacology?
• Why are politicians so callous about citizens’ health that they even consider granting the privilege to prescribe powerful, sometimes high-risk psychotropics to persons who have had no professional medical training?
• Why is there so much criticism about off-label use of antidepressants, mood stabilizers, and atypical antipsychotics, when 85% of DSM-IV-TR psychiatric disorders do not have any FDA-approved drug treatment?³ Do “armchair critics” have a better idea for treating serious psychiatric disorders?
• Why is there such a scarcity of long-term psychiatric beds for patients who need that type of supervised care? And why do we psychiatrists tolerate managed care policies that dictate discharging psychotic or suicidal inpatients after only 5 or 6 days of treatment?
• Why does the stigma of mental illness persist, even though 75 million (1 in 4) Americans has a diagnosable mental disorder in any given year?⁴
• Finally, why are we standing still when the dysfunctional public mental health system was declared “in shambles” in 2003 by the final report of the President’s New Freedom Commission on Mental Health?⁵

So there, I feel better sharing a few things that bug me. Feel free to share your gripes with me. Better still, let’s try to develop some solutions to these problems.

Every psychiatrist and mental health professional encourages patients to “express your feelings.” Venting produces a cathartic effect, especially if frustrations have been harbored for a while. So I thought I should practice what I preach and tell you some things that annoy me about the contemporary state of psychiatry, which might bother some of you as well.

• Why have we allowed our patients to be relocated from hospitals to jails and prisons? How were the mentally ill transformed from “patients” to “felons?” State hospitals have been shuttered, but correctional facilities are a growth industry.
• Why have community-based mentally ill patients become “clients,” as if mental healthcare was a business transaction? Would cardiologists or oncologists accept labeling their patients as “clients?” No chance!
• Why did psychiatrists shed their white coats and psychiatric nurses replace their professional uniforms with street clothes? Medical attire used to serve as an important environmental cue that an inpatient ward was a “therapeutic facility.” Nowadays, hospitalized psychotic and bipolar patients think they are in a hotel (or, as one of my psychotic patients said recently, in a spaceship).
• Why is it that the more powerful the evidence that mental illnesses are brain disorders with neurobiological roots, the more “demedicalized” the community mental health system has become?
• Why don’t practitioners actively support research when they know that every treatment in clinical practice today was once a research project? The breakthrough treatments of tomorrow are being researched today. One simple way clinicians can help accelerate treatment discoveries is to refer patients to therapeutic clinical trials at local academic institutions.
• When are we going to overcome bureaucratic obstacles and give our public sector seriously mentally ill patients the continuity of care they need and deserve? Changing psychiatrists frequently puts patients at risk for diagnostic and treatment errors, repeated mistakes, and difficulties building rapport and therapeutic alliances.
• Why aren’t more psychiatrists collaborating actively with primary care providers? Up to 50% of chronically mentally ill individuals have serious medical conditions,¹ and up to 50% of primary care patients have mental health problems.² We desperately need an integrated, collaborative approach to mind-body illnesses.
• Why have psychiatrists in community mental health settings been reduced to writing prescriptions and doing “med checks” during sessions too brief to allow for the optimal approach of integrating psychotherapy with psychopharmacology?
• Why are politicians so callous about citizens’ health that they even consider granting the privilege to prescribe powerful, sometimes high-risk psychotropics to persons who have had no professional medical training?
• Why is there so much criticism about off-label use of antidepressants, mood stabilizers, and atypical antipsychotics, when 85% of DSM-IV-TR psychiatric disorders do not have any FDA-approved drug treatment?³ Do “armchair critics” have a better idea for treating serious psychiatric disorders?
• Why is there such a scarcity of long-term psychiatric beds for patients who need that type of supervised care? And why do we psychiatrists tolerate managed care policies that dictate discharging psychotic or suicidal inpatients after only 5 or 6 days of treatment?
• Why does the stigma of mental illness persist, even though 75 million (1 in 4) Americans has a diagnosable mental disorder in any given year?⁴
• Finally, why are we standing still when the dysfunctional public mental health system was declared “in shambles” in 2003 by the final report of the President’s New Freedom Commission on Mental Health?⁵

So there, I feel better sharing a few things that bug me. Feel free to share your gripes with me. Better still, let’s try to develop some solutions to these problems.

Every psychiatrist and mental health professional encourages patients to “express your feelings.” Venting produces a cathartic effect, especially if frustrations have been harbored for a while. So I thought I should practice what I preach and tell you some things that annoy me about the contemporary state of psychiatry, which might bother some of you as well.

• Why have we allowed our patients to be relocated from hospitals to jails and prisons? How were the mentally ill transformed from “patients” to “felons?” State hospitals have been shuttered, but correctional facilities are a growth industry.
• Why have community-based mentally ill patients become “clients,” as if mental healthcare was a business transaction? Would cardiologists or oncologists accept labeling their patients as “clients?” No chance!
• Why did psychiatrists shed their white coats and psychiatric nurses replace their professional uniforms with street clothes? Medical attire used to serve as an important environmental cue that an inpatient ward was a “therapeutic facility.” Nowadays, hospitalized psychotic and bipolar patients think they are in a hotel (or, as one of my psychotic patients said recently, in a spaceship).
• Why is it that the more powerful the evidence that mental illnesses are brain disorders with neurobiological roots, the more “demedicalized” the community mental health system has become?
• Why don’t practitioners actively support research when they know that every treatment in clinical practice today was once a research project? The breakthrough treatments of tomorrow are being researched today. One simple way clinicians can help accelerate treatment discoveries is to refer patients to therapeutic clinical trials at local academic institutions.
• When are we going to overcome bureaucratic obstacles and give our public sector seriously mentally ill patients the continuity of care they need and deserve? Changing psychiatrists frequently puts patients at risk for diagnostic and treatment errors, repeated mistakes, and difficulties building rapport and therapeutic alliances.
• Why aren’t more psychiatrists collaborating actively with primary care providers? Up to 50% of chronically mentally ill individuals have serious medical conditions,¹ and up to 50% of primary care patients have mental health problems.² We desperately need an integrated, collaborative approach to mind-body illnesses.
• Why have psychiatrists in community mental health settings been reduced to writing prescriptions and doing “med checks” during sessions too brief to allow for the optimal approach of integrating psychotherapy with psychopharmacology?
• Why are politicians so callous about citizens’ health that they even consider granting the privilege to prescribe powerful, sometimes high-risk psychotropics to persons who have had no professional medical training?
• Why is there so much criticism about off-label use of antidepressants, mood stabilizers, and atypical antipsychotics, when 85% of DSM-IV-TR psychiatric disorders do not have any FDA-approved drug treatment?³ Do “armchair critics” have a better idea for treating serious psychiatric disorders?
• Why is there such a scarcity of long-term psychiatric beds for patients who need that type of supervised care? And why do we psychiatrists tolerate managed care policies that dictate discharging psychotic or suicidal inpatients after only 5 or 6 days of treatment?
• Why does the stigma of mental illness persist, even though 75 million (1 in 4) Americans has a diagnosable mental disorder in any given year?⁴
• Finally, why are we standing still when the dysfunctional public mental health system was declared “in shambles” in 2003 by the final report of the President’s New Freedom Commission on Mental Health?⁵

So there, I feel better sharing a few things that bug me. Feel free to share your gripes with me. Better still, let’s try to develop some solutions to these problems.

Change is coming for continuing medical education (CME). A cloud of conflict of interest has shrouded any person or activity that receives pharmaceutical funding, including the venerable institution of CME. This is a big deal because all health practitioners rely on CME programs to meet requirements for license renewal and to keep up with medical advances.

Attitudes about commercial support of CME have changed, with some organizations calling for elimination of all industry funding (Table). Pressure to strip commercial support from CME is equivalent to draining blood from a living organism; it can have dire consequences if done precipitously.

CME has grown rapidly into a big business. Its commercial support quadrupled from $300 million to $1.2 billion between 1998 and 2006, according to the Accreditation Council for Continuing Medical Education. Another $1.2 billion came from other sources. Here is who received the $2.4 billion in CME funds in 2006: 34% went to publishing and medical education companies, 33% to physician organizations, 18% to medical schools, and 15% to other CME providers (such as hospitals).

The urgent question about sustaining CME has become: where will $1.2 billion come from if not from industry? Eleemosynary is likely to provide only a fraction of support. Shifting the cost to attendees could make CME fees prohibitively high (>$1,000 for a 1-day symposium).

It’s no wonder that CME providers feel anxious about the perception of undue influence on their programs, while at the same time pharmaceutical companies are pulling back from sponsoring CME. But how do psychiatric practitioners feel about this issue?

Table

Industry support of CME: Evolution of standards

Practitioners’ attitudes about CME funding

To find out, I polled 200 mental health professionals at a CME symposium in October 2008. The results are interesting and contrary to what one might assume to be prevailing perceptions. Most respondents (69%) said industry support biases CME content at least sometimes. Most agreed CME programs with multiple sponsors are less likely to be biased than single-sponsored programs (29% “strongly agree,” 53% “agree”). Nearly all (90%) said CME programs generally meet their educational needs.

If CME funding must come from nonindustry sources, only 17% of respondents favored higher registration fees. Other sources they endorsed were private foundations (39%), online CME (30%), and grand rounds (5%). View complete survey results.

Based on these responses, here are my predictions:

• CME will survive, but its funding sources will change.
• Industry sponsorship of CME will not disappear, but it will decline substantially (a trend that has already begun). Funds from multiple pharmaceutical companies might be pooled and allocated to applicants by a third party.
• Eleemosynary will probably increase, but charity will remain a small fraction of CME support.
• The number of CME programs will decline (the American Psychiatric Association has cut sponsored CME symposia at their annual meeting by about 70%).
• Online CME will grow.
• Health professionals will increasingly participate in online learning through educational Web sites, including those of medical journals.

Change is coming for continuing medical education (CME). A cloud of conflict of interest has shrouded any person or activity that receives pharmaceutical funding, including the venerable institution of CME. This is a big deal because all health practitioners rely on CME programs to meet requirements for license renewal and to keep up with medical advances.

Attitudes about commercial support of CME have changed, with some organizations calling for elimination of all industry funding (Table). Pressure to strip commercial support from CME is equivalent to draining blood from a living organism; it can have dire consequences if done precipitously.

CME has grown rapidly into a big business. Its commercial support quadrupled from $300 million to $1.2 billion between 1998 and 2006, according to the Accreditation Council for Continuing Medical Education. Another $1.2 billion came from other sources. Here is who received the $2.4 billion in CME funds in 2006: 34% went to publishing and medical education companies, 33% to physician organizations, 18% to medical schools, and 15% to other CME providers (such as hospitals).

The urgent question about sustaining CME has become: where will $1.2 billion come from if not from industry? Eleemosynary is likely to provide only a fraction of support. Shifting the cost to attendees could make CME fees prohibitively high (>$1,000 for a 1-day symposium).

It’s no wonder that CME providers feel anxious about the perception of undue influence on their programs, while at the same time pharmaceutical companies are pulling back from sponsoring CME. But how do psychiatric practitioners feel about this issue?

Table

Industry support of CME: Evolution of standards

Practitioners’ attitudes about CME funding

To find out, I polled 200 mental health professionals at a CME symposium in October 2008. The results are interesting and contrary to what one might assume to be prevailing perceptions. Most respondents (69%) said industry support biases CME content at least sometimes. Most agreed CME programs with multiple sponsors are less likely to be biased than single-sponsored programs (29% “strongly agree,” 53% “agree”). Nearly all (90%) said CME programs generally meet their educational needs.

If CME funding must come from nonindustry sources, only 17% of respondents favored higher registration fees. Other sources they endorsed were private foundations (39%), online CME (30%), and grand rounds (5%). View complete survey results.

Based on these responses, here are my predictions:

• CME will survive, but its funding sources will change.
• Industry sponsorship of CME will not disappear, but it will decline substantially (a trend that has already begun). Funds from multiple pharmaceutical companies might be pooled and allocated to applicants by a third party.
• Eleemosynary will probably increase, but charity will remain a small fraction of CME support.
• The number of CME programs will decline (the American Psychiatric Association has cut sponsored CME symposia at their annual meeting by about 70%).
• Online CME will grow.
• Health professionals will increasingly participate in online learning through educational Web sites, including those of medical journals.

Change is coming for continuing medical education (CME). A cloud of conflict of interest has shrouded any person or activity that receives pharmaceutical funding, including the venerable institution of CME. This is a big deal because all health practitioners rely on CME programs to meet requirements for license renewal and to keep up with medical advances.

Attitudes about commercial support of CME have changed, with some organizations calling for elimination of all industry funding (Table). Pressure to strip commercial support from CME is equivalent to draining blood from a living organism; it can have dire consequences if done precipitously.

CME has grown rapidly into a big business. Its commercial support quadrupled from $300 million to $1.2 billion between 1998 and 2006, according to the Accreditation Council for Continuing Medical Education. Another $1.2 billion came from other sources. Here is who received the $2.4 billion in CME funds in 2006: 34% went to publishing and medical education companies, 33% to physician organizations, 18% to medical schools, and 15% to other CME providers (such as hospitals).

The urgent question about sustaining CME has become: where will $1.2 billion come from if not from industry? Eleemosynary is likely to provide only a fraction of support. Shifting the cost to attendees could make CME fees prohibitively high (>$1,000 for a 1-day symposium).

It’s no wonder that CME providers feel anxious about the perception of undue influence on their programs, while at the same time pharmaceutical companies are pulling back from sponsoring CME. But how do psychiatric practitioners feel about this issue?

Table

Industry support of CME: Evolution of standards

Practitioners’ attitudes about CME funding

To find out, I polled 200 mental health professionals at a CME symposium in October 2008. The results are interesting and contrary to what one might assume to be prevailing perceptions. Most respondents (69%) said industry support biases CME content at least sometimes. Most agreed CME programs with multiple sponsors are less likely to be biased than single-sponsored programs (29% “strongly agree,” 53% “agree”). Nearly all (90%) said CME programs generally meet their educational needs.

If CME funding must come from nonindustry sources, only 17% of respondents favored higher registration fees. Other sources they endorsed were private foundations (39%), online CME (30%), and grand rounds (5%). View complete survey results.

Based on these responses, here are my predictions:

• CME will survive, but its funding sources will change.
• Industry sponsorship of CME will not disappear, but it will decline substantially (a trend that has already begun). Funds from multiple pharmaceutical companies might be pooled and allocated to applicants by a third party.
• Eleemosynary will probably increase, but charity will remain a small fraction of CME support.
• The number of CME programs will decline (the American Psychiatric Association has cut sponsored CME symposia at their annual meeting by about 70%).
• Online CME will grow.
• Health professionals will increasingly participate in online learning through educational Web sites, including those of medical journals.

During this economic recession, it feels as if the entire country is suffering from an “adjustment disorder with anxiety and dysphoria.” I don’t want to depress you further, but doesn’t it seem that psychiatry is having its own recession, reflected in our profession’s collective psyche?

Despite breathtaking discoveries in neuroscience, clinical advances are stalling because of a “perfect storm” of setbacks for our profession. For example:

• Second-generation “atypical” antipsychotics seem to be falling from grace after several effectiveness studies denigrated them for metabolic side effects and claimed they are not more efficacious than the older generation agents. Disillusionment followed.
• Hopes for a new generation of glutamatergic antipsychotics were dashed when clinical trials failed to show that a novel metabotropic glutamate partial agonist was superior to placebo.
• A palpable “funk” prevails as clinicians yearn for better antidepressants, with a more rapid onset of action, antisuicidal efficacy, and minimal side effects. The wait continues.
• The media and idealistic crusaders criticize off-label prescribing, without knowing that 85% of psychiatric diagnoses in DSM-IV-TR have no approved medications. Because symptoms of many psychiatric disorders overlap, we try to relieve patients’ suffering by prescribing medications that are FDA-approved for other indications. When it comes to off-label prescribing, it seems we’re damned if we do and damned if we don’t.
• Relentless demonization of pharmaceutical companies has made them the whipping boy for corporate America. No wonder they are downsizing and investing less in drug research and development; the return on their investments has become unpredictable. No one else develops new psychiatric drugs, so our patients will suffer if the pharmaceutical slump worsens.
• Academic researchers have been publicly “tarred and feathered” for collaborating with and advising pharmaceutical companies (such as in conducting FDA clinical trials) because they—like researchers in other fields—receive consulting income from those companies. This perception that any link with the “evil” pharmaceutical companies is a major sin has cast a pall over vital academic-industry collaborative research to develop new drug treatments for severe and disabling psychiatric disorders.
• Even the American Psychiatric Association (APA) is under enormous stress. In response to political pressure, APA is divesting itself of $1.5 million in CME grants from pharmaceutical sponsors.¹ The popular industry-sponsored symposia were cut back at APA’s 2009 meeting and are being eliminated in 2010. Because of this abrupt loss of revenue, APA has deeply cut its organizational structure and function, adding to the “recession atmosphere” in psychiatry.
• DSM-V committee members also are being scrutinized for ties to the pharmaceutical industry. I have faith in my colleagues’ objectivity and believe they will base their decisions on scientific evidence alone. Because perception is everything, however, some highly qualified psychiatric nosologists could not participate because they had received honoraria from pharmaceutical companies—a routine activity for a research expert. Attacks on the credibility of leading psychiatrists are demoralizing to these individuals who have made important contributions and puzzling to the many psychiatrists who look up to them.
• Psychiatrists also have been accused of “overdiagnosing” attention-deficit/hyperactivity disorder and bipolar disorder in children. Yet it may be that advances in recognizing these disorders in children have led to better and earlier identification. Psychiatrists who are diagnosing and treating those seriously ill children feel unappreciated and unfairly accused by persons who know little about mental illnesses.

A ‘TARP’ for psychiatry?

In this economic recession, the U.S. government created the Troubled Asset Relief Program (TARP) for stressed financial institutions. Does psychiatry need its own “TARP” (Targeted Assistance to Revive Psychiatry)?

I think we can help ourselves by educating the media, politicians, and community leaders about psychiatry’s tremendous contributions to the mental health and well-being of children, adults, and the elderly. We can and should refurbish our image and support each other until psychiatry’s recession is over. Just as we always reassure our patients, let’s remind ourselves that “this too shall pass.”

During this economic recession, it feels as if the entire country is suffering from an “adjustment disorder with anxiety and dysphoria.” I don’t want to depress you further, but doesn’t it seem that psychiatry is having its own recession, reflected in our profession’s collective psyche?

Despite breathtaking discoveries in neuroscience, clinical advances are stalling because of a “perfect storm” of setbacks for our profession. For example:

• Second-generation “atypical” antipsychotics seem to be falling from grace after several effectiveness studies denigrated them for metabolic side effects and claimed they are not more efficacious than the older generation agents. Disillusionment followed.
• Hopes for a new generation of glutamatergic antipsychotics were dashed when clinical trials failed to show that a novel metabotropic glutamate partial agonist was superior to placebo.
• A palpable “funk” prevails as clinicians yearn for better antidepressants, with a more rapid onset of action, antisuicidal efficacy, and minimal side effects. The wait continues.
• The media and idealistic crusaders criticize off-label prescribing, without knowing that 85% of psychiatric diagnoses in DSM-IV-TR have no approved medications. Because symptoms of many psychiatric disorders overlap, we try to relieve patients’ suffering by prescribing medications that are FDA-approved for other indications. When it comes to off-label prescribing, it seems we’re damned if we do and damned if we don’t.
• Relentless demonization of pharmaceutical companies has made them the whipping boy for corporate America. No wonder they are downsizing and investing less in drug research and development; the return on their investments has become unpredictable. No one else develops new psychiatric drugs, so our patients will suffer if the pharmaceutical slump worsens.
• Academic researchers have been publicly “tarred and feathered” for collaborating with and advising pharmaceutical companies (such as in conducting FDA clinical trials) because they—like researchers in other fields—receive consulting income from those companies. This perception that any link with the “evil” pharmaceutical companies is a major sin has cast a pall over vital academic-industry collaborative research to develop new drug treatments for severe and disabling psychiatric disorders.
• Even the American Psychiatric Association (APA) is under enormous stress. In response to political pressure, APA is divesting itself of $1.5 million in CME grants from pharmaceutical sponsors.¹ The popular industry-sponsored symposia were cut back at APA’s 2009 meeting and are being eliminated in 2010. Because of this abrupt loss of revenue, APA has deeply cut its organizational structure and function, adding to the “recession atmosphere” in psychiatry.
• DSM-V committee members also are being scrutinized for ties to the pharmaceutical industry. I have faith in my colleagues’ objectivity and believe they will base their decisions on scientific evidence alone. Because perception is everything, however, some highly qualified psychiatric nosologists could not participate because they had received honoraria from pharmaceutical companies—a routine activity for a research expert. Attacks on the credibility of leading psychiatrists are demoralizing to these individuals who have made important contributions and puzzling to the many psychiatrists who look up to them.
• Psychiatrists also have been accused of “overdiagnosing” attention-deficit/hyperactivity disorder and bipolar disorder in children. Yet it may be that advances in recognizing these disorders in children have led to better and earlier identification. Psychiatrists who are diagnosing and treating those seriously ill children feel unappreciated and unfairly accused by persons who know little about mental illnesses.

A ‘TARP’ for psychiatry?

In this economic recession, the U.S. government created the Troubled Asset Relief Program (TARP) for stressed financial institutions. Does psychiatry need its own “TARP” (Targeted Assistance to Revive Psychiatry)?

I think we can help ourselves by educating the media, politicians, and community leaders about psychiatry’s tremendous contributions to the mental health and well-being of children, adults, and the elderly. We can and should refurbish our image and support each other until psychiatry’s recession is over. Just as we always reassure our patients, let’s remind ourselves that “this too shall pass.”

During this economic recession, it feels as if the entire country is suffering from an “adjustment disorder with anxiety and dysphoria.” I don’t want to depress you further, but doesn’t it seem that psychiatry is having its own recession, reflected in our profession’s collective psyche?

Despite breathtaking discoveries in neuroscience, clinical advances are stalling because of a “perfect storm” of setbacks for our profession. For example:

• Second-generation “atypical” antipsychotics seem to be falling from grace after several effectiveness studies denigrated them for metabolic side effects and claimed they are not more efficacious than the older generation agents. Disillusionment followed.
• Hopes for a new generation of glutamatergic antipsychotics were dashed when clinical trials failed to show that a novel metabotropic glutamate partial agonist was superior to placebo.
• A palpable “funk” prevails as clinicians yearn for better antidepressants, with a more rapid onset of action, antisuicidal efficacy, and minimal side effects. The wait continues.
• The media and idealistic crusaders criticize off-label prescribing, without knowing that 85% of psychiatric diagnoses in DSM-IV-TR have no approved medications. Because symptoms of many psychiatric disorders overlap, we try to relieve patients’ suffering by prescribing medications that are FDA-approved for other indications. When it comes to off-label prescribing, it seems we’re damned if we do and damned if we don’t.
• Relentless demonization of pharmaceutical companies has made them the whipping boy for corporate America. No wonder they are downsizing and investing less in drug research and development; the return on their investments has become unpredictable. No one else develops new psychiatric drugs, so our patients will suffer if the pharmaceutical slump worsens.
• Academic researchers have been publicly “tarred and feathered” for collaborating with and advising pharmaceutical companies (such as in conducting FDA clinical trials) because they—like researchers in other fields—receive consulting income from those companies. This perception that any link with the “evil” pharmaceutical companies is a major sin has cast a pall over vital academic-industry collaborative research to develop new drug treatments for severe and disabling psychiatric disorders.
• Even the American Psychiatric Association (APA) is under enormous stress. In response to political pressure, APA is divesting itself of $1.5 million in CME grants from pharmaceutical sponsors.¹ The popular industry-sponsored symposia were cut back at APA’s 2009 meeting and are being eliminated in 2010. Because of this abrupt loss of revenue, APA has deeply cut its organizational structure and function, adding to the “recession atmosphere” in psychiatry.
• DSM-V committee members also are being scrutinized for ties to the pharmaceutical industry. I have faith in my colleagues’ objectivity and believe they will base their decisions on scientific evidence alone. Because perception is everything, however, some highly qualified psychiatric nosologists could not participate because they had received honoraria from pharmaceutical companies—a routine activity for a research expert. Attacks on the credibility of leading psychiatrists are demoralizing to these individuals who have made important contributions and puzzling to the many psychiatrists who look up to them.
• Psychiatrists also have been accused of “overdiagnosing” attention-deficit/hyperactivity disorder and bipolar disorder in children. Yet it may be that advances in recognizing these disorders in children have led to better and earlier identification. Psychiatrists who are diagnosing and treating those seriously ill children feel unappreciated and unfairly accused by persons who know little about mental illnesses.

A ‘TARP’ for psychiatry?

In this economic recession, the U.S. government created the Troubled Asset Relief Program (TARP) for stressed financial institutions. Does psychiatry need its own “TARP” (Targeted Assistance to Revive Psychiatry)?

I think we can help ourselves by educating the media, politicians, and community leaders about psychiatry’s tremendous contributions to the mental health and well-being of children, adults, and the elderly. We can and should refurbish our image and support each other until psychiatry’s recession is over. Just as we always reassure our patients, let’s remind ourselves that “this too shall pass.”

Comment on this article

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.

Comment on this article

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.

Comment on this article

On recent hospital rounds with residents and medical students, a medical student presented a 20-year-old man with first-episode psychosis. The student mentioned that the patient admitted to hearing voices, and the admission note in the patient’s chart referred simply to “AH+” (auditory hallucinations present)

I was disappointed. This sparse description of a key psychotic symptom ignored rich details that could provide important clinical and safety information about the patient. So I suggested that the students and residents ask this patient many more questions about his AH, including:

• How did the voices start—suddenly or gradually? With or without drug use? Do they speak clearly, or are they muffled and indistinct? Was the patient alarmed when the voices first occurred? Did he hear voices during childhood?
• Does the patient hear 1 voice, 2 voices, or more? Male or female? Recognizable voices of relatives or friends, or voices of strangers? Living or dead people? Are the voices from nonhuman entities such as God, Satan, or a computer?
• Do the voices come from inside or outside the patient’s head? Does he hear them from the left side, right side, or both? Does the patient recognize them as his own thoughts spoken out loud?
• Do the voices speak directly to the patient in the first person or talk about the patient in the third person? If there is more than 1 voice, do they converse about the patient? Do they run a commentary about the patient’s actions, feelings, or thoughts? Does the patient talk back to the voices occasionally, regularly, or not at all?
• Do the voices give orders? Do these orders include harming oneself or others? Can the patient resist those commands, or is he worried that he might carry them out?
• Do the voices insult or praise the patient? Do they upset the patient or make him laugh by cracking jokes? Does the patient laugh to himself because of what the voices say? Do they make the patient cry or scream in frustration?
• Do the voices occur continuously or sporadically throughout the day? What makes them more intense, decrease, or stop? Are they worse at any time during the day? Do they stop when the patient is eating, watching TV, reading a magazine, talking to someone, doing a crossword puzzle, or playing a video game? Do they ever wake the patient at night? Do they sometimes prevent him from falling asleep?
• Have the voices led the patient to become more paranoid or suspicious toward others? Do they make him depressed, anxious, or agitated? Do the voices tell the patient he is guilty of sins or that he will go to hell to be punished?
• Does the patient want the voices to stop, or does he like hearing them, regard them as “friends,” and would miss them if they disappeared? Have the voices stopped in the past in response to medication, and did the patient discontinue the medication just to have the voices return?
• Are the AHs triggers for or sometimes accompanied by other types of hallucinations—such as visual, olfactory, gustatory, or somatic—related to the persons behind the voices?

In my experience, clinicians rarely retrieve and document the wealth of data available about AHs when assessing persons with psychosis. I recommend that clinicians include such details in the initial mental status exam of a patient with psychosis.

Details of AH paint a unique picture of each patient. They provide a useful baseline to monitor the effects of treatment and may warn of potential harm to the patient or others. They help me to empathize with my patients and understand the perceptual chaos that causes their torment and anguish. This empathy can strengthen the therapeutic alliance as we work to restore normalcy to young lives shattered by psychosis.

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.

Comment on this article

Can you imagine an internist starting insulin for a patient with diabetes without obtaining a baseline glucose level? How would that internist know from visit to visit whether treatment was working and to what extent? How would he or she know how and when to adjust the dose to achieve hyperglycemia remission and a normal serum level?

If our medical colleagues wouldn’t dream of treating patients without measuring the symptoms of illness, why should psychiatric practice be different? Why aren’t psychiatrists measuring patients’ depression, anxiety, mania, or psychosis before and after starting psychopharmacologic agents?

Standardized tools unused

I recently surveyed a sample of Current Psychiatry readers, asking about their use of standard measurement instruments in clinical practice. I conducted this online survey as part of the needs assessment for a CME workshop I am planning at the University of Cincinnati. As I expected, most of the respondents indicated that they do not utilize any of 4 clinical rating scales routinely used in the evidence-based controlled trials required for FDA approval of psychiatric medications. These scales—which most said they had heard of or read about—include:

• Positive and Negative Syndrome Scale (PANSS) for schizophrenia
• Young Mania Rating Scale (YMRS) for bipolar mania
• Hamilton Depression Rating Scale (HAM-D) for unipolar depression
• Montgomery-Åsberg Depression Rating Scale (MADRS) for bipolar depression.

Lack of time was the most common reason respondents cited for not using these tools. Many preferred that their patients complete self-rating scales instead. Although I agree that patient self-ratings can be useful, they lack the objectivity and comprehensiveness of a clinician’s observation.

Many good reasons

One of the most important goals in modern psychiatric practice is to achieve remission, not just partial symptomatic response. Remission of depression, bipolar disorder, or schizophrenia is defined by a quantitative threshold measured on a standard rating scale. Therefore, we must use the pertinent rating scales if we wish to document that our patients achieve remission, which is the gateway to recovery and return to social and vocational functioning.

I believe psychiatrists should use standardized clinical rating scales because it is good medical practice that our patients need. Standardized measurements would enable all psychiatrists to use the same language relating to severity of illness, response, or remission. Then, when we read records of patients referred to us or cover while a colleague is on vacation, the numerical assessment combined with clinical impressions in the notes will facilitate continuity of care and guide ongoing treatment.

Let’s face it: the contents of many psychiatric charts are too general (“patient is doing better”) or vague (“patient partially improved”). Very few practitioners have time to cite whether or not every sign and symptom persists at a mild, moderate, or severe degree. By adopting standard rating scales, busy practitioners could do more (through better documentation) in less time (such as by circling the severity number corresponding to the symptoms listed on the scale).

Coming soon: Electronic medical records

The Obama administration’s economic stimulus package includes $19 billion to incentivize the adoption of universal electronic medical records (a 10-year goal set in 2004 by President Bush). Clinicians in facilities that have adopted e-medical records can enter clinical ratings with the click of a mouse. Issues beyond symptoms—such as functioning, quality of life, relationships, coping with stresses, etc.—can be addressed in the handwritten progress note text. (By the way, standard rating scales exist for those issues, too.)

Let us not wait for the time when reimbursement may become linked to documenting PANSS, YMRS, or MADRS scores at initial evaluations and follow-up visits. The time has come for psychiatrists—like our medical colleagues—to upgrade to objective, measurement-based practice and documentation. Improving the quality of inadequately informative or outright deficient medical records would be good for the patient and the practitioner. The quality of psychiatric treatment in the clinical setting should be no less rigorous than the controlled research trials that led to approval of the treatments.