Editing The Canadian Journal of Psychiatry 1995–2004

Abstract

Over the period 1995 to 2004,1 had the privilege of being the editor-in-chief of the now 50-year-old Canadian Journal of Psychiatry. These years abounded with changes and challenges. What we published in the Journal reflected what was happening in psychiatry, and in society as a whole. My term spanned the transition from the 20th to the 21 st century, which was anticipated with substantial anxiety in respect to computer systems. (Nothing happened!) Somewhat later, the dot-corn bubble did burst and bring reality into this increasingly important field. The events of September 11, 2001, shocked North America with experiences suffered by many in other parts of the world but new to this region. The pace of life in general has accelerated over these years. Similarly, there has been an acceleration of communication by e-mail, cellphones, and pagers, all of which require immediate response. The demand to increase performance each year is creating an atmosphere of increased tension and anxiety, with stress leave being the politically correct response to those affected. This labelling, however, is a refusal to acknowledge the high percentages who suffer mental illness over their lifetime. This also reflects the reality that stigma remains vigorous, despite commendable efforts by individuals and organizations to educate and enlighten the public. The persistence of stigma associated with mental illness also indicates that, like it or not, psychiatry is still not highly respected in the medical-hospital culture. During my years as editor-in-chief, the practice of psychiatry changed radically. Longer-stay beds were closed or transferred to general hospitals. These financially driven requirements have led to a revolving-door syndrome characterized by repeated admissions and swamped emergency rooms. (This is not to oppose the concept of reintegration but to politely suggest that some individuals still require a longer stay, particularly since community services that have been put in place do not consistently meet the needs of the chronically ill.) Community treatment orders have addressed this issue, with considerable success reported so far. Further, the advent of new medications with fewer immediate side effects virtually requires their use in serious mental illness. The shortage of beds has led to the use of multiple medications (and, unfortunately, to a decline in the personal aspect of treatment, as indicated by this direct quote from a psychiatrist with a long-term patient: If you want psychotherapy, go to a psychotherapist). The bottom line in today's psychiatry is defined by more patients, fewer staff, and increased medication-to the point that medications introduced primarily for one condition are now used for many and the link between diagnosis and selected treatment has become blurred across schizophrenia, affective disorders, dementia, and the treatment of troublesome youth. If there is a problem there must be a pill! Those psychiatrists who continue to provide psychotherapy and psychoanalysis face a dilemma. The public perception of psychiatry is still that of the couch, yet the value of what we provide is demeaned by the widespread acceptance of counsellors (with training and practice unspecified) for any and every need for personal care. Allied to this change has been the increasing influence of administration on clinical service provision, best demonstrated by the concept expressed in the 1991 Barer-Stoddard report (1) that doctors drive the cost of health care, so fewer doctors must equal less cost. The result of cutting back medical school places despite dire predictions of disaster is only now being fully felt by the public. Both the number of doctors and the hours they can practise have been constrained in favour of other priorities and compete with the considerable value of newer diagnostic tests. Similar are the measures of psychiatrists' performance, such as a length-of-stay that is often shorter than needed for medication to be effective. …