Progress In Psychiatry Research Articles

An Integrated General Theory of Psychopathology and Suicide

This article presents biological meta-theory that is intended to serve as a shared key to progress in psychiatry and suicidology. It argues that diverse forms of psychopathology, widely believed to cause suicide, may instead manifest the organism’s last-ditch efforts to avoid that lethal outcome. The analysis elaborates on the pain-brain theory, which views suicide as a costly by-product of human sapience, with the cost managed by serial lines of evolved anti-suicide defenses. The last of these, emergency interventions that function to block the enacting of suicidal ideas, are hypothesized to display in an array of psychiatric phenomena, including mood disorders, substance and behavioral addictions, and psychoses.The etiology of psychiatric syndromes is explained in three parts. First, psychopathology associates with suicidal ideation because the two outcomes share a causal root: the individual’s experience of chronic psychological pain (psychache), subject to a threshold of intellectual maturation. An evolved system utilizes these inputs to evaluate the risk of suicide and to release commensurately severe countermeasures, which manifest non-specifically as psychopathology. Second, the configuration of symptoms is determined by other aspects of individual differences: reflecting contextual needs, individualized blends of motivational and/or cognitive modifications seek to make lethal escape unnecessary and/or impracticable. Third, psychiatric syndromes can be understood as often-observed, heterogeneous clusters of anti-suicide symptoms, combined with psychache and side effects.The model integrates ultimate and proximate explanation, aligns with the epidemiological record, and yields testable predictions. It offers foundations for advancing research, policy, and clinical practice in suicide prevention and mental health.

Progress and Change in Psychiatry Coming Too Slowly

Back to table of contents Previous article Next article From the PresidentFull AccessProgress and Change in Psychiatry Coming Too SlowlyVivian B. Pender, M.D.Vivian B. PenderSearch for more papers by this author, M.D.Published Online:21 Apr 2022https://doi.org/10.1176/appi.pn.2022.05.5.8The book Desperate Remedies: Psychiatry’s Turbulent Quest to Cure Mental Illness by Andrew Scull, Ph.D., is being published this month. The book, based on a carefully researched history of psychiatry, provides a critical assessment of the psychiatric enterprise. In the rush to find cures for psychiatric illnesses, Scull believes that there has been a disappointing lack of focus on patients. Rather, the profession has been gnawed away from within by various self-interested factions and subjected to multipronged attacks from without.It is important to remember psychiatry’s beginnings. Even in 1886, Pliny Earle, M.D. (a superintendent of several asylums and a founder of APA and the AMA), lamented that “in the present state of our knowledge, no classification of insanity can be erected on a pathological basis, for the simple reason that, with but slight exceptions, the pathology of the disease is unknown. …” Furthermore, he noted that there was an overwhelming reliance on reporting of symptoms (Pliny Earle Papers, 1886, box 1, folder 3, American Antiquarian Society, Worcester, Mass.).Nearly a century and a half later, nothing, it seems, has substantially changed. The connection between the general lack of progress in psychiatry may reflect that previous research may not have included “all of us.”Steven Hyman, M.D., a former director of the National Institute of Mental Health who did much to support shifting psychiatric research to focus on biology, neuroscience, and genetics, had by 2007 concluded that “it is probably premature to bring neurobiology into the formal classification of mental disorders” (Nature Reviews Neuroscience, September 2007).The Beth Israel Deaconess Medical Center Grand Rounds recently presented highlights from the 2021 American College of Neuropsychopharmacology meeting. Although many advances have been made in understanding complicated plastic brain functions, almost none were clinically applicable, and when they were, the therapeutic mechanism was poorly understood. The summary of the conference was a validation of Scull’s treatise and Earle’s lamentation that nothing has significantly changed; however, it was noted that the quest of big pharma over the last several decades to develop drugs and thereby earn huge profits is gradually being replaced by new, radiologically based interventions into the brain. As a result, prior optimism over the prospect of highly specific drug-based cures is changing to pessimism over the current state of affairs using nonspecific pharmacologic “blunt instruments” and a return to physical treatment instruments.Few patients and their families escape the ravaging effects of mental illness; however, nobody escapes its social burdens. Just as Black patients were once segregated in separate wards or in entirely separate institutions, marginalization, discrimination, and exclusion persist in psychiatry to this day. The form is different, but the premise is the same. Racism, sexism, and other forms of discrimination continue to impact individuals in all sectors of society, including the economy, housing, education, and the criminal justice system. And with respect to physical and mental health, the cumulative disadvantages of poverty and prejudice are vividly demonstrated by high rates of maternal mortality and lower life expectancy. Unsurprisingly, during the COVID-19 pandemic, racial and ethnic communities had less access to medical and mental health care than Whites. The lack of correcting the effect of bias on contemporary research on racial disparities in psychiatric treatment is dismaying. Even organized psychiatry did not come forth with an apology for its support of structural racism until January 2021. We are now working on righting our wrongs by taking systematic steps to eliminate racism within our organization.If research in genetics, neuroscience, and microbiomics do not show signs of producing practical advances for all of humanity, supporting programs may tire of funding such endeavors.A renewed focus on the prevention of traumatic life experiences such as living in poverty and witnessing violence would provide a welcome shift in the psychiatric paradigm. Rather than exclusively seeking more biological cures for downstream psychiatric illness that are socially driven, patients and the public may benefit from less prescribing and more listening to the desperate voices that can be heard if one pays attention.Incidentally, this is my last column as your president, and you will be in good hands under the leadership of incoming President Rebecca Brendel, M.D., J.D. While my term may be ending, I will never stop fighting to ensure that all patients—regardless of background and ability to pay—have access to high-quality care and are treated with the dignity and respect they deserve. It is incumbent on all psychiatrists to do the same. ■“Can Neuroscience Be Integrated Into the DSM-V?” ISSUES NewArchived

A Retrospective Review of the Clinical Significance of the Outcome Questionnaire (OQ) Measure in Patients at a Psychiatric Adult Partial Hospital Program.

IntroductionOutcome Questionnaire (OQ) measure is becoming a more popular assessment tool for monitoring treatment progress in psychiatry at different settings including inpatient and outpatient settings. It can also be used in non-clinical populations. However, little is known about the evaluation of this tool in the Adult Partial Hospital Program (PHP).MethodsWe conducted a study among patients in an Adult PHP where we extracted data from the OQ analysis program recorded for patients from January 1, 2015 to July 31st, 2020.ResultsWe studied a total of 742 patients among which 509 (68.4%) were males. The mean age was 38.58 ± 14.86 years. Most of the patients had depressive disorder (56.9%). The mean numbers of days on admission were 17.37 ± 25.29 days. There is a consistent decrease in the total score average OQ score from initial to final measure with the year 2019 being 31.99 followed by 2017 (30.05) then 2020 (29.56) then 2015/2016 (28.38) and 2018 (27.27) p < 0.001. Also, for treatment progress it was observed that in years 2015/2016, there was significant improvement in 71.67% of the patients; in 2017, there was significant improvement in 78.53% of the patients; in 2018, there was significant improvement in 77.71% of the patients; while in 2019, there was significant improvement in 76.05% of the patients, and in 2020, there was significant improvement in 70.18% of the patients.ConclusionThe direct benefit of the OQ measure to patients is to provide objective measurements of assessing clinical improvement or deterioration in the treatment progress of their clinical condition. Our study has proved that this is a useful tool to assess such in the Adult PHP.

Parsing Psychiatric Heterogeneity Through Common and Unique Circuit-Level Deficits

It is increasingly recognized that progress in psychiatry is hindered by the heterogeneity of clinical diagnoses as codified by the DSM. Progress in other fields of medicine has in large part been predicated upon parsing clinical phenomena that appear similar into biologically homogeneous subtypes that align with prognosis and treatment response. At present, psychiatric diagnostic entities remain defined by clinical signs and symptoms and are likely to be composed of multiple distinct circuit- and system-level biological abnormalities. Similarly, it is recognized that there may be common circuit-level deficits (e.g., reward system abnormalities) that are present in many disorders. Identifying common mechanisms across disorders and parsing heterogeneity within clinical diagnoses has the potential to accelerate efforts in precision medicine where diagnosis, prognosis, and therapeutics can be tailored to the individual.

Toward Precision Psychiatry in Bipolar Disorder: Staging 2.0.

Personalized treatment is defined as choosing the “right treatment for the right person at the right time.” Although psychiatry has not yet reached this level of precision, we are on the way thanks to recent technological developments that may aid to detect plausible molecular and genetic markers. At the moment there are some models that are contributing to precision psychiatry through the concept of staging. While staging was initially presented as a way to categorize patients according to clinical presentation, course, and illness severity, current staging models integrate multiple levels of information that can help to define each patient's characteristics, severity, and prognosis in a more precise and individualized way. Moreover, staging might serve as the foundation to create a clinical decision-making algorithm on the basis of the patient's stage. In this review we will summarize the evolution of the bipolar disorder staging model in relation to the new discoveries on the neurobiology of bipolar disorder. Furthermore, we will discuss how the latest and future progress in psychiatry might transform current staging models into precision staging models.

New journey, new mission: bolstering international communication about mental health

In the wake of the rapid economy and society development, phenomena such as industrialisation, urbanisation, marketisation and the ageing of the population have shown an accelerating trend. As a result,...

New Tools for New Research in Psychiatry: A Scalable and Customizable Platform to Empower Data Driven Smartphone Research.

BackgroundA longstanding barrier to progress in psychiatry, both in clinical settings and research trials, has been the persistent difficulty of accurately and reliably quantifying disease phenotypes. Mobile phone technology combined with data science has the potential to offer medicine a wealth of additional information on disease phenotypes, but the large majority of existing smartphone apps are not intended for use as biomedical research platforms and, as such, do not generate research-quality data.ObjectiveOur aim is not the creation of yet another app per se but rather the establishment of a platform to collect research-quality smartphone raw sensor and usage pattern data. Our ultimate goal is to develop statistical, mathematical, and computational methodology to enable us and others to extract biomedical and clinical insights from smartphone data.MethodsWe report on the development and early testing of Beiwe, a research platform featuring a study portal, smartphone app, database, and data modeling and analysis tools designed and developed specifically for transparent, customizable, and reproducible biomedical research use, in particular for the study of psychiatric and neurological disorders. We also outline a proposed study using the platform for patients with schizophrenia.ResultsWe demonstrate the passive data capabilities of the Beiwe platform and early results of its analytical capabilities.ConclusionsSmartphone sensors and phone usage patterns, when coupled with appropriate statistical learning tools, are able to capture various social and behavioral manifestations of illnesses, in naturalistic settings, as lived and experienced by patients. The ubiquity of smartphones makes this type of moment-by-moment quantification of disease phenotypes highly scalable and, when integrated within a transparent research platform, presents tremendous opportunities for research, discovery, and patient health.

Pure animal phobia is more specific than other specific phobias: epidemiological evidence from the Zurich Study, the ZInEP and the PsyCoLaus.

Interest in subtypes of mental disorders is growing in parallel with continuing research progress in psychiatry. The aim of this study was to examine pure animal phobia in contrast to other specific phobias and a mixed subtype. Data from three representative Swiss community samples were analysed: PsyCoLaus (n=3720), the ZInEP Epidemiology Survey (n=1500) and the Zurich Study (n=591). Pure animal phobia and mixed animal/other specific phobias consistently displayed a low age at onset of first symptoms (8-12years) and clear preponderance of females (OR>3). Meanwhile, other specific phobias started up to 10years later and displayed almost a balanced sex ratio. Pure animal phobia showed no associations with any included risk factors and comorbid disorders, in contrast to numerous associations found in the mixed subtype and in other specific phobias. Across the whole range of epidemiological parameters examined in three different samples, pure animal phobia seems to represent a different entity compared to other specific phobias. The etiopathogenetic mechanisms and risk factors associated with pure animal phobias appear less clear than ever.

The tradition and future of JAMA Psychiatry.

This issue of JAMA Psychiatry marks the transition to a new editor in chief. Three outstanding psychiatrists edited the journal when it was known as Archives of General Psychiatry: Roy R. Grinker Sr, MD (1959-1969), Daniel X. Freedman, MD (1970-1993), and Jack D. Barchas, MD (1994-2001). For the last 13 years, Joseph T. Coyle, MD, continued this tradition masterfully through the electronic evolution of the journal and the transition to JAMA Psychiatry in January 2012. I thank Joe for his outstanding leadership and his mentorship, especially during my time with him as the associate editor of Archives of General Psychiatry (2003-2011). The new editorial office will include Dost Ongur (associate editor), Jennifer Blackford (managing editor), Ira Phillips (web editor), and Helena Chmura Kraemer (statistical editor). Twenty leading experts in psychiatric research will advise us as members of the editorial board. The landscapeofscientific journals is rapidlychanging.The majorprocesses includingmanuscript submission, review,and dissemination are now fully electronic. Content is published online first each week and republished in a formal issue released inprint andonlineonceamonth.Thishas reduced turnaroundtimes fromsubmissiontoacceptancetopublicationand hasmade informationquicklyaccessible.Mostofusdonotvisit libraries anymore;wenowbrowse journals on our computers and mobile devices. As part of The JAMA Network, we have access toa full arrayofmultispecialty journal content andelectronicplatformsandwewill use themtooptimally support authors and readers. JAMAPsychiatrypublishes cutting-edge research and seminal contributions to thepsychiatric literature. The Original Investigations will remain the core of the journal. We are receiving an ever-increasing number of submissions, now more than 1300 per year. We will add more reviews, meta-analyses, and opinion pieces that can shape our field. While we cover the full spectrum of psychiatric researchsubmittedbycolleaguesaroundtheworld, thereareseveral areas of particular interest. Epidemiological research has been a major strength and we will continue to publish the scholarly analysis of archival data sets. We will also focus on epidemiological studies that can shed light on the mechanisms of risk factors, such as traumaorenvironmental exposure.Epidemiological studydesigns cannowbemarriedwith the in-depth analysis of geneticsandneuroimaging toprovide trulymechanistic insights into pathogenesis. The increasingly complex genetic analysis of mental disorders is crucial for our understanding of disease mechanisms and the identification of treatment targets, ultimately leading to personalized psychiatry. We invite psychiatric geneticists to submit their best research to JAMA Psychiatry. Neuroimaging is now a widely available technology. Wewill especially be looking for longitudinal neuroimaging studies that provide unique insights into the neuralmechanisms of treatment response,diseasecourse, and outcome.Only thenwill neuroimaging become useful to clinicians in their clinical assessment of patients. Finally, we will emphasize treatment studies, particularly clinical trials of both pharmacological andnonpharmacological interventions.They remain the touchstone of scientific progress in psychiatry. I am excited about new opportunities for JAMA Psychiatry. We will discuss strategies for psychiatric research, translate scientificdiscoveries into clinical practice, andexplore the impact of psychiatry on society. While scientists are unraveling themysteries of thehumanmind, this newknowledgehas had limited impacton thecurrentpracticeand teachingofpsychiatry.Most of our diagnostic concepts havebeenwithus for 100 years and many of our treatments were discovered more than 50 years ago, often by serendipity. This lack of progress has led some to ask for radical changes in howwe studymental illness, including the creation of a neuroscience-based diagnostic system. JAMAPsychiatrywill provide a forum to explore the scientific structureof psychiatry byasking:what can we know and what should we do? To close the gap between psychiatric research and psychiatric practice, we need to teach neuroscience principles in the clinical setting. The core teaching of psychiatry (psychopathology, diagnostic formulation, and treatment planning) does not rely on even a basic concept of how the brain gives rise to the mind. Many good psychiatrists readily admit that they do not consider neuroscience a necessary knowledge base for their practice. We need to train a new generation of psychiatrists who are grounded in classical psychiatry but also eager to interpret brain scans, cognitive neuroscience experiments, genetic analyses, and epidemiological data sets. This will only work if wemake researchmore relevant in the clinical setting. For example, when a clinician assesses a patient for anxiety symptoms vs panic attacks, does it help to know about the roles of the amygdala and the bed nucleus of the stria terminalis? Only when neuroscience models support clinical decision making will our research advance the clinical practice of psychiatry. JAMA Psychiatry will expand the Stephan Heckers, MD Opinion

The many faces of dissociation: opportunities for innovative research in psychiatry.

It has been claimed that the progress of psychiatry has lagged behind that of other medical disciplines over the last few decades. This may suggest the need for innovative thinking and research in psychiatry, which should consider neglected areas as topics of interest in light of the potential progress which might be made in this regard. This review is concerned with one such field of psychiatry: dissociation and dissociative disorders. Dissociation is the ultimate form of human response to chronic developmental stress, because patients with dissociative disorders report the highest frequency of childhood abuse and/or neglect among all psychiatric disorders. The cardinal feature of dissociation is a disruption in one or more mental functions. Dissociative amnesia, depersonalization, derealization, identity confusion, and identity alterations are core phenomena of dissociative psychopathology which constitute a single dimension characterized by a spectrum of severity. While dissociative identity disorder (DID) is the most pervasive condition of all dissociative disorders, partial representations of this spectrum may be diagnosed as dissociative amnesia (with or without fugue), depersonalization disorder, and other specified dissociative disorders such as subthreshold DID, dissociative trance disorder, acute dissociative disorders, and identity disturbances due to exposure to oppression. In addition to constituting disorders in their own right, dissociation may accompany almost every psychiatric disorder and operate as a confounding factor in general psychiatry, including neurobiological and psycho-pharmacological research. While an anti- dissociative drug does not yet exist, appropriate psychotherapy leads to considerable improvement for many patients with dissociative disorders.

Resilience of institutional culture: mental nursing in a decade of radical change

Mental nursing has continued to be neglected in the history of psychiatry. This paper considers the impact of a decade of radical developments on the role and outlook of nurses in British mental hospitals during the 1930s. The Mental Treatment Act 1930 introduced voluntary admission for early, supposedly treatable cases, although there was paucity of effective treatment. In the mid-1930s shock therapies, administered with great enthusiasm by asylum doctors, promised to cure insanity by physical means. Although these were important milestones in the progress of psychiatry, for the majority of nurses and patients life continued much as before. Despite advances in training, working conditions and therapeutic activity, the institutional culture of nursing was remarkably resilient to the forces of change.

Commentary to the articles of M. Stier (Normative preconditions for the assessment of mental disorder) and T. Schramme (On the autonomy of the concept of disease in psychiatry)

Commentary to the articles of M. Stier (Normative preconditions for the assessment of mental disorder) and T. Schramme (On the autonomy of the concept of disease in psychiatry)

Commentary: Psychiatric Training for Physicians: A Call to Modernize

Genetics and the neurosciences are changing the knowledge base of psychiatry. The authors of this commentary argue that if psychiatry is to meet the considerable challenges associated with assimilating the rapid advance of those sciences and populating the field with new leaders who will contribute to such advances, fundamental problems in psychiatric education and training must be addressed. The authors argue that three domains in particular require change--an overemphasis on the outmoded diagnostic system, a residual attachment to archaic psychoanalytic constructs, and an unwarranted confidence in current therapeutic capabilities. They then propose first steps aimed at remedying each domain. The authors suggest increased curricular emphasis on taxonomic approaches distinct from that of the current Diagnostic and Statistical Manual of Mental Disorders system, enhanced attention to and teaching of core cognitive neuroscientific concepts, and a concerted emphasis on the development of skills needed for critical evaluation of the empiric bases of therapeutics. They conclude that progress in psychiatry requires that educators shift their emphases toward what is currently known and being learned--including the scientific sophistication needed to assess such claims of knowledge--and away from taxonomic and conceptual systems that are demonstrably flawed, if not simply wrong.

Recovering at the cost of amnesia?

Despite the great progress of psychiatry, many of its fundamental problems remain unresolved. Obviously, new ideas that expand the present understanding of such problems are useful. In this paper, the following hypothesis is proposed: mental disorders are caused by hypoxic phenomena, stimulating hypertrophied growth of a neural network; treatment should be directed towards the damaging of abnormal elements of this network; successful treatment is inevitably accompanied by moderate retrograde amnesia. Based on this hypothesis, the connection between etiology, pathogenesis, and therapy of mental disorders is described, the role of retrograde amnesia is shown, and potential new methods of treatment (shaking, vibration, and ultrasound) are predicted. To test the hypothesis, some means are discussed. The first means is based on the analysis of the reasons of unsuccessful clinical trials of the method of mental disorders treatment by acute hypoxic hypoxia (USA, 1938-1940). Such a method, according to the hypothesis, should damage the abnormal elements of a neural network as a result of acute hypoxia. Analysis of the equipment and procedure shows that the trials were unsuccessful as a result of insufficiently powerful hypoxic influence. Improvements to this method are proposed. When using this method, it is advisable to measure the cerebral blood oxygenation index and reduce it by regulating the oxygen concentration in the hypoxic gas mixture given to the patient. This reduction should continue until the patient reaches a state of moderate retrograde amnesia. It is also advisable to note the blood oxygenation index value at the moment when the patient lapses into unconsciousness, and then, on the basis of this value, estimate a necessary power (i.e., acuteness and duration) of hypoxic hypoxia. Other means for testing the hypothesis are also discussed: retrospective analysis of the results of electroconvulsive therapy, and testing the predicted methods of treatment.

The DSM-IV-TR ‘Glossary of Technical Terms’: A Reappraisal

Many of the entries in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition – Text Revision (DSM-IV-TR) are problematic along multiple axes, including, but not limited to, clarity, logical coherence, factual content, redundancy, and ambiguity. These problems pose multiple barriers to clear, efficient, and accurate communication among those who work in clinical contexts or among those involved in psychological or psychiatric research. These barriers to communication, accurate concept formation, and clinical clarity affect diagnostic validity and reliability in a manner that imperils progress in psychiatry and psychology on a grand scale. This essay focuses on some of the most egregious problematic entries in the DSM-IV-TR’s ‘Glossary of Technical Terms’. It is meant to be a prolegomenon to a thorough revision of the Glossary in preparation for the projected 5th edition of the DSM.

Schizophrénie et culture : réalités et perspectives à partir de l’expérience tunisienne

Despite notable advances in the field, schizophrenia is still considered a major public health problem on international level. The combination of frequency, chronicity and severity make it, for some authors, the "cancer of mental disorders". However, according to the many cross-cultural studies, in particular, the two mammoth research projects of the WHO (IPSS and DOSMED, it is now irrefutable that the course and outcome of schizophrenia are better in patients from developing countries. The reasons for better outcome and more favorable course of schizophrenia in developing countries are still far from clear and remain speculative. We have carried out a study among a population of schizophrenic patients admitted to our hospital during the past year, to question the issues of outcome, course and prognosis in Tunisia, which is an emerging country, ranking half-way between the most and the least developed countries. It appears that the outcome of schizophrenia is similar to that of developed countries. A community survey reported an annual prevalence of 5.7 and an incidence of 3. 266 patients with schizophrenia were admitted between August 2003 and 2004, representing 40% of the whole hospitalized population; 80% were former patients who had been hospitalized an average of 8 times. One patient out of five will be readmitted at least once within the same year. Only 16.5% were married, and 10% had a regular job, in spite of a high level of education. A chronic course without remission is not unusual and long stay patients now account for a fourth of the hospital population. It seems clearly and paradoxically that the course and outcome of schizophrenia is deteriorating and getting closer to what is observed in the industrialized societies. The same trend was observed in the western countries during the last centuries, leading some authors to claim that schizophrenia is a modern disease, which appeared in the XIX(e) century and spread in the XX(e). Besides, other than the controversy regarding the recent evolution of its incidence, it seems that we are not witnessing the anticipated decrease in incidence that comes with the therapeutic progress and the decline in fertility among individuals with schizophrenia. We shall discuss three hypotheses to try to explain the aggravation of schizophrenia along with the economic development: the heterogeneity of the disease with two clinical presentations: a benign form (good prognosis), more frequent in developing countries, and a severe form, observed mainly in developed societies. The progress in medicine and gynecology-obstetrics, which contributes to the survival of patients with serious schizophrenia and the vulnerable newborn exposed to multiple assaults and risk factors related to birth. The progress in psychiatry that is selecting the more serious subtypes of schizophrenia, which are overrepresented today. Research issues pertaining to course and outcome of schizophrenia are still unresolved. It is likely that prognosis of schizophrenia varies according to the economic development rather than to the culture. This observation could open new research and prevention perspectives.

Human Rights Progress in Psychiatry: More Apparent Than Real (Observations and Reflections on Life in the Texas Mental Health Courts)

The history of modern psychiatry includes a legacy of coercion and infamous physical and mechanical treatments, on the one hand, and progress in human rights, particularly patient rights, on the other. The purpose of this article is to remind readers that this modern progress in psychiatry is more apparent than real. The author’s experience with recent cases in the mental health courts is discussed in order to demonstrate the ongoing abuse of human rights in psychiatry. A brief look at other aspects of the current mental health climate in the United States is also provided, along with considerations of informed consent.

Editorial: The Significance of Psychotherapy in the Age of Neuroscience

Anyone engaged in the progress of psychiatry and psychotherapy must ask themselves the disquieting question whether we are about to split into a neuroscientific camp on the one hand and a psychosocial camp on the other—despite all stated beliefs about a common biopsychosocial point of view. A supplement of Schizophrenia Bulletin devoted entirely to the psychotherapy of schizophrenic patients therefore merits an editorial that addresses the specific significance of psychotherapeutic approaches in relation to recent discoveries in neuroscience.

Psychiatrists Warn Congress About Danger of Cutting Research Funds

Psychiatrists Warn Congress About Danger of Cutting Research Funds

Action for Mental Health Systems Transformation

ohn Talbott demonstrated remarkable foresight into a future in which we now grapple with many of the troubles he predicted. The staggering increase in the number of homeless persons, our inability to provide high-quality care to patients who have severe mental illness, system breakdowns, and inadequate payment mechanisms were all on Talbott’s list of concerns. A critical part of his vision was to shift care from antiquated mental hospitals to the community. With considerable energy, commitment to the most disenfranchised patients, and a willingness to speak out authoritatively and authentically, he defined the issues that are salient to the progress of psychiatry. The recent report from the President’s New Freedom Commission on Mental Health (1) might have been written by Talbott. The authors conclude that today’s mental health care system is a “patchwork relic” that frustrates “opportunity for recovery.” Only a “fundamental transformation of the Nation’s approach to mental health care” that goes beyond “traditional reform measures” will make a difference. These conclusions echo Talbott’s warnings in 1985: “Psychiatry faces a vast array of problems today, including its inability to implement programs for the chronic mentally ill and to apply principles of differential therapeutics, the lack of funds for community services, and the continuing severe fragmentation of the psychiatric delivery nonsystem. Old solutions will not suffice.” As a psychiatrist whose career has spanned this period and who has worked with homeless people for the past 15 years, I am offered, through this commentary, an opportunity to reflect on the circumstances of the most severely ill, stigmatized, and disaffiliated patients, many of whom are homeless. I also speak for a family member who is a consumer of services. When I first became a psychiatrist, I worked in settings such as public mental hospitals that were like Frederick Wiseman’s “snake pits.” Private care was sometimes better, but too often it was unavailable to clients with severe mental illness. Providers were often unable or unwilling to address the needs of persons with severe mental illness and those who were homeless. From today’s vantage point, 20 years ago may have represented the heyday of patient care. With the acceptance of psychodynamic theory and a real understanding of the context of patients’ lives, providers talked to patients about their experiences and believed in the salutary effect of the relationship. A “trusting relationship” was viewed as the linchpin of treatment. Medication was equally important, working in tandem with “talking therapies.” The balance tipped in later years toward medication, a necessary but not sufficient ingredient of treatment. Today, patients languish on inpatient psychiatric units, heavily medicated, with no therapeutic milieu and attended by staff who are too overburdened to spend adequate time talking with them. Since Talbott wrote about the “shame of the cities,” we have witnessed an epidemic of homelessness, with increasing numbers of women and children on the streets. Although the why of homelessness is deeply embedded in structural factors such as the income gap between rich and poor and the crisis in the availability of decent, affordable housing, those who are most affected by these forces reflect our society’s prejudices about who is most expendable. Just as in a game of musical chairs, someone is left standing