Psychiatric Encounters Research Articles

Extracting social support and social isolation information from clinical psychiatry notes: comparing a rule-based natural language processing system and a large language model.

Social support (SS) and social isolation (SI) are social determinants of health (SDOH) associated with psychiatric outcomes. In electronic health records (EHRs), individual-level SS/SI is typically documented in narrative clinical notes rather than as structured coded data. Natural language processing (NLP) algorithms can automate the otherwise labor-intensive process of extraction of such information. Psychiatric encounter notes from Mount Sinai Health System (MSHS, n = 300) and Weill Cornell Medicine (WCM, n = 225) were annotated to create a gold-standard corpus. A rule-based system (RBS) involving lexicons and a large language model (LLM) using FLAN-T5-XL were developed to identify mentions of SS and SI and their subcategories (eg, social network, instrumental support, and loneliness). For extracting SS/SI, the RBS obtained higher macroaveraged F1-scores than the LLM at both MSHS (0.89 versus 0.65) and WCM (0.85 versus 0.82). For extracting the subcategories, the RBS also outperformed the LLM at both MSHS (0.90 versus 0.62) and WCM (0.82 versus 0.81). Unexpectedly, the RBS outperformed the LLMs across all metrics. An intensive review demonstrates that this finding is due to the divergent approach taken by the RBS and LLM. The RBS was designed and refined to follow the same specific rules as the gold-standard annotations. Conversely, the LLM was more inclusive with categorization and conformed to common English-language understanding. Both approaches offer advantages, although additional replication studies are warranted.

Virtual Versus In-Person Follow-up After a Psychiatric Emergency Visit: A Population-Based Cohort Study: Suivi virtuel opposé à en personne après une visite à l’urgence psychiatrique : une étude de cohorte dans la population

Objective With increased utilization of virtual care in mental health, examining its appropriateness in various clinical scenarios is warranted. This study aimed to compare the risk of adverse psychiatric outcomes following virtual versus in-person mental health follow-up care after a psychiatric emergency department (ED) visit. Methods Using population-based health administrative data in Ontario (2021), we identified 28,232 adults discharged from a psychiatric ED visit who had a follow-up mental health visit within 14 days postdischarge. We compared those whose first follow-up visit was virtual (telephone or video) versus in-person on their risk for experiencing either a repeat psychiatric ED visit, psychiatric hospitalization, intentional self-injury, or suicide in the 15–90 days post-ED visit. Cox proportional hazard models generated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs), adjusted for age, income quintile, psychiatric hospitalization, and intentional self-injury in the 2 years prior to ED visit. We stratified by sex and diagnosis at index ED visits based on the International Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) coding. Results About 65% ( n = 18,354) of first follow-up visits were virtual, while 35% ( n = 9,878) were in-person. About 13.9% and 14.6% of the virtual and in-person groups, respectively, experienced the composite outcome, corresponding to incidence rates of 60.9 versus 74.2 per 1000 person-years (aHR 0.95, 95% CI 0.89 to 1.01). Results were similar for individual elements of the composite outcome, when stratifying by sex and index psychiatric diagnosis, when varying exposure (7 days) and outcome periods (60 and 30 days), and comparing “only” virtual versus “any” in-person follow-up during the 14-day follow-up. Conclusions and Relevance These results support virtual care as a modality to increase access to follow-up after an acute care psychiatric encounter across a wide range of diagnoses. Prospective trials to discern whether this is due to the comparable efficacy of virtual and in-person care, or due solely to appropriate patient selection may be warranted.

Changes in Service Use After Participation in an Intensive Outpatient Program Among Adults With Posttraumatic Stress Disorder.

Intensive outpatient programs (IOPs) have been shown to reduce posttraumatic stress disorder (PTSD) symptoms in veteran populations. The aim of this study was to examine the association between IOP participation and inpatient psychiatric and mental health-related emergency department (ED) encounters among patients with PTSD. This is a retrospective cohort study among 258 adults with PTSD who participated in the IOP at Kaiser Permanente Oakland Medical Center between January 1, 2017, and December 31, 2018. The authors compared changes in inpatient psychiatric hospitalizations and mental health-related ED encounters from the year before vs after the first IOP engagement. Bivariate analyses comparing ED and inpatient utilization pre- and post-IOP engagement, stratified by sociodemographic variables were conducted using paired t-tests and McNemar's test. Conditional multivariable logistic regression was performed to assess the odds of psychiatric utilization. Participants were more likely to have ≥ 1 inpatient psychiatric encounter (28.7% vs 15.9%; p < 0.01) and ≥ 1 mental health-related ED encounter (24.8% vs 18.2%; p = 0.04) pre-IOP vs post-IOP. The authors' multivariable analysis demonstrated that patients experienced a 56% reduction in the odds of inpatient psychiatric encounters (adjusted odds ratio = 0.42, 95% confidence interval: 0.26-0.68, p < 0.01) and a 35% reduction in mental health-related ED encounters (adjusted odds ratio = 0.63, 95% confidence interval: 0.40-1.00, p = 0.05) post-IOP vs pre-IOP. This study demonstrated a significant reduction in inpatient psychiatric hospitalizations and mental health-related ED visits among patients with PTSD in the year following participation in an IOP. These findings support the use of IOPs for patients with PTSD to reduce the likelihood of intensive service use.

Insight From Integrating Objective Data Into Psychiatric Encounters

We present the case of Mr. B, who was part of a NIMH-funded, longitudinal, observational study (2013 to 2016) that recruited unmedicated participants who were experiencing a range of palpable symptoms related to states of negative affect and who were assessed on multiple objective measures. A feedback report was generated based on Mr. B's multimodal measurements. One of the authors, LMW, along with Mr. B's psychotherapist, discussed the results with Mr. B in a feedback session. Mr. B's objective testing profile was consistent with a history of trauma, allowing him for the first time to be comfortable with revealing to his therapist that he experienced early-life trauma. Mr. B's case highlights several known advantages of integrating objective data into psychiatric encounters, including reducing stigma, motivating patients to pursue treatment, and improving clinical outcomes by aiding in identification of the right treatment, which is the ultimate goal of precision psychiatry. [ Psychiatr Ann . 2024;54(4):e113–e118.]

Reflections on the use of patient records: Privacy, ethics, and reparations in the history of psychiatry.

One of the most common questions we get asked as historians of psychiatry is "do you have access to patient records?" Why are people so fascinated with the psychiatric patient record? Do people assume they are or should be available? Does access to the patient record actually tell us anything new about the history of psychiatry? And if we did have them, what can, or should we do with them? In the push to both decolonize and personalize the history of psychiatry, as well as make some kind of account or reparation for past mistakes, how can we proceed in an ethical manner that respects the privacy of people in the past who never imagined their intensely personal psychiatric encounter as subject for future historians? In this paper, we want to think through some of the issues that we deal with as white historians of psychiatry especially at the intersection of privacy, ethics, and racism. We present our thoughts as a conversation, structured around questions we have posed for ourselves, and building on discussions we have had together over the past few years. We hope that they act as a catalyst for further discussion in the field.

The impact of COVID-19 on psychiatric clinical encounters among low-income racially-diverse children.

There is a lack of longitudinal data to examine the impact of COVID-19 on all types of clinical encounters among United States, underrepresented BIPOC (Black, Indigenous, and people of color), children. This study aims to examine the changes in all the outpatient clinical encounters during the pandemic compared to the baseline, with particular attention to psychiatric encounters and diagnoses. This study analyzed 3-year (January 2019 to December 2021) longitudinal clinical encounter data from 3,394 children in the Boston Birth Cohort, a US urban, predominantly low-income, Black and Hispanic children. Outcomes of interest were completed outpatient clinical encounters and their modalities (telemedicine vs. in person), including psychiatric care and diagnoses, primary care, emergency department (ED), and developmental and behavioral pediatrics (DBP). The study children's mean (SD) age is 13.9 (4.0) years. Compared to 2019, psychiatric encounters increased by 38% in 2020, most notably for diagnoses of adjustment disorders, depression, and post-traumatic stress disorders (PTSD). In contrast, primary care encounters decreased by 33%, ED encounters decreased by 55%, and DBP care decreased by 16% in 2020. Telemedicine was utilized the most for psychiatric and DBP encounters and the least for primary care encounters in 2020. A remarkable change in 2021 was the return of primary care encounters to the 2019 level, but psychiatric encounters fluctuated with spikes in COVID-19 case numbers. Among this sample of US BIPOC children, compared to the 2019 baseline, psychiatric encounters increased by 38% during 2020, most notably for the new diagnoses of adjustment disorder, depression, and PTSD. The 2021 data showed a full recovery of primary care encounters to the baseline level but psychiatric encounters remained sensitive to the pandemic spikes. The long-term impact of the pandemic on children's mental health warrants further investigation.

Psychiatric emergencies among urban youth during COVID-19: Volume and acuity in a multi-channel program for the publicly insured

This study sought to characterize changes in the utilization of psychiatric emergency services among children and adolescents during distinct phases of 2020, as compared with prior years. We conducted a retrospective review of electronic health records from January 2018 through December 2020 that included all encounters made by patients under age 21. We then analyzed data for the 15,045 youth psychiatric encounters during the study period. Encounter volume in 2020 was significantly lower than prior years in March through May (IRR, 0.44; 95% CI, 0.40–0.49), May through July (IRR, 0.63; 95% CI, 0.56–0.71), and October through December (IRR, 0.76; 95% CI, 0.70–0.83). Encounters for youth with primary psychotic disorders remained at typical levels throughout 2020. Among older adolescents and youth with anxiety disorders, pervasive developmental disorders, and substance use disorders, encounter volume was significantly lower than prior years only during the initial lockdown period. There were significantly more encounters than normal conducted by mobile crisis units, including via telehealth, in July through October (IRR, 1.31; 95% CI, 1.06–1.62) and October through December (IRR, 1.28; 95% CI, 1.05–1.55) of 2020. Differences in patterns of encounter volume based on sociodemographic and clinical characteristics highlight subgroups of youth who may have been particularly vulnerable to acute mental health problems during periods of social distancing and isolation. Proactive efforts to engage vulnerable youth in outpatient treatment during periods of increased infectivity may help prevent increasing symptoms from reaching the point of crisis.

Is 'another' psychiatry possible?

In this paper, we examine a number of approaches that propose new models for psychiatric theory and practices: in the way that they incorporate 'social' dimensions, in the way they involve 'communities' in treatment, in the ways that they engage mental health service users, and in the ways that they try to shift the power relations within the psychiatric encounter. We examine the extent to which 'alternatives' - including 'Postpsychiatry', 'Open Dialogue', the 'Power, Threat and Meaning Framework' and Service User Involvement in Research - really do depart from mainstream models in terms of theory, practice and empirical research and identify some shortcomings in each. We propose an approach which seeks more firmly to ground mental distress within the lifeworld of those who experience it, with a particular focus on the biopsychosocial niches within which we make our lives, and the impact of systematic disadvantage, structural violence and other toxic exposures within the spaces and places that constitute and constrain many everyday lives. Further, we argue that a truly alternative psychiatry requires psychiatric professionals to go beyond simply listening to the voices of service users: to overcome epistemic injustice requires professionals to recognise that those who have experience of mental health services have their own expertise in accounting for their distress and in evaluating alternative forms of treatment. Finally we suggest that, if 'another psychiatry' is possible, this requires a radical reimagination of the role and responsibilities of the medically trained psychiatrist within and outside the clinical encounter.

Bonds of time and space: Divination and the psychiatric encounter.

This essay examines the intersections between divination and psychiatry in the context of modern Chinese history. Throughout the 20th century, subsequent political regimes attempted to drive an ontological wedge between psychiatry, which was deemed scientific, and divination, which was deemed superstitious. While the dichotomy between science and superstition remains a powerful ideology today, it belies the use of divination as a psychotherapeutic tool. Occult practices such as fortune telling and shamanism complement the application of technical psychiatric skills by serving a crucial moral and interpersonal function, one that has important implications for the practice of mental healthcare both within and beyond Asia.

Racial and Ethnic Differences in Psychiatry Resident Prescribing: a Quality Improvement Education Intervention to Address Health Equity.

Quality improvement (QI) tools can identify and address health disparities. This paper describes the use of resident prescriber profiles in a novel QI curriculum to identify racial and ethnic differences in antidepressant and antipsychotic prescribing. The authors extracted medication orders written by 111 psychiatry residents over an 18-month period from an electronic medical record and reformatted these into 6133 unique patient encounters. Binomial logistic models adjusted for covariates assessed racial and ethnic differences in antipsychotic or antidepressant prescribing in both emergency and inpatient psychiatric encounters. A multinomial model adjusted for covariates then assessed racial and ethnic differences in primary diagnosis. Models also examined interactions between gender and race/ethnicity. Black (adjusted OR 0.66; 95% CI, 0.50-0.87; p < 0.01) and Latinx (adjusted OR, 0.65; 95% CI, 0.49-0.86; p < 0.01) patients had lower odds of receiving antidepressants relative to White patients despite diagnosis. Black and Latinx patients were no more likely to receive antipsychotics than White patients when adjusted for diagnosis. Black (adjusted OR 3.85; 95% CI, 2.9-5.2) and Latinx (adjusted OR 1.60; 95% CI, 1.1-2.3) patients were more likely to receive a psychosis than a depression diagnosis when compared to White patients. Gender interactions with race/ethnicity did not significantly change results. Our findings suggest that racial/ethnic differences in antidepressant prescription likely result from alternatively higher diagnosis of psychotic disorders and prescription of antipsychotics in Black and Latinx patients. Prescriber profiles can serve as a powerful tool to promote resident QI learning around the effects of structural racism on clinical care.

Comparison of Efficacy in Depression and Stigma Reduction in Virtual In-Office Psychiatric Encounters with Virtual Out-of-Office Psychiatric Encounters among Adults in Louisiana

The primary purpose of this study was to conduct a clinical trial to compare the provision of psychiatric evaluation and medication interventions in a Virtual Out of Office format (VOO) with the provision of psychiatric evaluation and medication interventions in a Virtual in-Office psychiatric encounter (VIO) among adults in Louisiana seeking psychiatric services for the treatment of depression. This study was classified as a pretest-posttest control group noninferiority double-blind experimental design. Each patient took a self-rated instrument at baseline and at week 8. The study tested the two interventions (VOO and VIO) by way of changes in overall function, changes in perceptions of stigma, and changes in rates of presentism. The final sample was 150 total number randomly assigned and 120 eligible participants providing usable data with 75 participants in VIO treatment group and 45 participants in VOO treatment group. The Virtual-Out-of-Office (VOO) treatment level was more effective in reducing the perceived Stigma associated with receiving psychiatric treatment than for the Virtual-in- Office (VIO) treatment. The VOO group had a significant reduction in the overall Stigma score (pre-test mean=1.97, post-test mean=1.52, t=2.629, df=24, p=0.015) and the Stigma-Intrinsic sub-scale score (pre-test mean=2.02, posttest mean=1.46, t=2.697, df=24, p=0.013) in the study. The VIO group showed no significant difference in any of the Stigma scores between pre-test and post-test measurements. The Virtual-Out-of-Office (VOO) treatment level was more efficacious in treating Depression associated with receiving psychiatric treatment than for the Virtual-in- Office (VIO) treatment group. The VOO group had a significant reduction in the Depression score (pre-test mean=3.05, post-test mean=1.71, t=5.406, df=24, p ≤ 0.001) in the study. Although the VIO group showed a significant reduction in the Depression score (pre-test mean=2.89, post-test mean=2.32, t=3.265, df=46, p=0.002), the VOO group showed a substantially greater reduction in Depression scores. Both treatment groups were effective in reducing depression which is consistent with literature and the practice of treating depression.

Commentary on ‘Mental Illness, Psychiatric Institutions, and the Singularity of Lives’

‘Mental Illness, Psychiatric Institutions, and the Singularity of Lives’, a chapter of 'Affliction' by Veena Das (2015), illustrates the sociocultural, familial, and personal factors that determine the trajectory of mental illness from its onset to treatment. Das discusses two case histories: a young boy suffering from psychotic illness and a young girl in conflict with her father. Both of them come from families residing in the urban slums of a large Indian metropolis. Reading this chapter gave us an opportunity to ask: how are cultural issues handled in psychiatric clinical encounters in India, and how are these taught to young trainee psychiatrists? The chapter also made us curious about anthropological methods and research vis-à-vis psychiatry.

33.2 ADDRESSING COMMON MENTAL HEALTH CONDITIONS IN TRANSGENDER YOUTH

Transgender youth display higher rates of mental health conditions as compared to their cisgender peers. Despite their relatively high rates of psychiatric encounters, transgender youth often perplex child and adolescent psychiatrists in clinical practice. This presentation will teach participants to recognize mental health conditions that occur at higher rates in transgender youth, consider mental health conditions that can complicate making a diagnosis of gender dysphoria, and conceptualize how mental health conditions impact treatment planning for youth with gender dysphoria. Furthermore, participants will learn how to approach the complex interplay between gender dysphoria and other commonly occurring mental health conditions, including mood disorders, anxiety, and autism spectrum disorder, in transgender youth.

Underutilization of the Emergency Department During the COVID-19 Pandemic.

IntroductionThe novel coronavirus 2019 (COVID-19) pandemic in the United States (US) prompted widespread containment measures such as shelter-in-place (SIP) orders. The goal of our study was to determine whether there was a significant change in overall volume and proportion of emergency department (ED) encounters since SIP measures began.MethodsThis was a retrospective, observational, cross-sectional study using billing data from January 1, 2017–April 20, 2020. We received data from 141 EDs across 16 states, encompassing a convenience sample of 26,223,438 ED encounters. We used a generalized least squares regression approach to ascertain changes for overall ED encounters, hospital admissions, and New York University ED visit algorithm categories.ResultsED encounters decreased significantly in the post-SIP period. Overall, there was a 39.6% decrease in ED encounters compared to expected volume in the pre-SIP period. Emergent encounters decreased by 35.8%, while non-emergent encounters decreased by 52.1%. Psychiatric encounters decreased by 30.2%. Encounters related to drugs and alcohol decreased the least, by 9.3% and 27.5%, respectively.ConclusionThere was a significant overall reduction in ED utilization in the post-SIP period. There was a greater reduction in lower acuity encounters than higher acuity encounters. Of all subtypes of ED encounters, substance abuse- and alcohol-related encounters reduced the least, and injury-related encounters reduced the most.

Clinician’s Subjective Experience in the Cross-Cultural Psychiatric Encounter

Introduction: The clinical encounter is still at the core of the psychiatric evaluation. Since the diagnostic process remains basically clinical in nature, several authors have addressed the complexity of the clinical reasoning process and highlighted the role played by intersubjective phenomena and clinician’s feelings. Some recent studies have supported the view of a significant link between the clinician’s subjective experience during the assessment and the diagnosis made. In a globalized world, this issue requires a careful reflection, since cultural differences may affect the intersubjective atmosphere of the encounter, which may indirectly influence the clinician’s thinking. Methods: We used a previously validated instrument, named Assessment of Clinician’s Subjective Experience (ACSE), to compare the clinician’s subjective experience during the evaluation of Italian patients with the subjective experience of the same clinician during the assessment of foreign patients. The 2 patient groups (n = 42 each) were individually matched for known potential confounders (age, sex, categorical diagnosis, and clinical severity). Results: We found no significant differences in mean scores on all ACSE dimensions (tension, difficulty in attune­ment, engagement, disconfirmation, and impotence), which suggests that cultural diversity did not substantially affect the clinician’s subjective experience. However, the lack of information about the native country and linguistic proficiency of about a quarter of foreign patients may have limited the possibility to detect subtle or specific differences, especially with regard to the clinician’s empathic attunement. Conclusions: Although further investigation is needed, our preliminary findings may have significant implications for the reflection upon the clinician’s empathic experience as well as pragmatic consequences for the act of psychiatric diagnosis in the cross-cultural encounter.

The role of psychopathology and nosology in 'precision' psychiatry

Psychopathology is the scientific exploration of abnormal mental experiences and behaviour that, for more than a century, has provided a Gestalt for psychiatric disorders and, thereby, the basis of psychiatric nosology. Having guided clinical and scientific progress in modern psychiatry, in consequence of considerable technical progress, psychopathology has been increasingly marginalised by neurobiological research. Albeit the precise, careful and qualified assessment of psychopathology has been a core skill of mental health professionals, today's curricula pay increasingly less attention to its training. However, because neurobiological models still have to prove their diagnostic superiority and despite all prophecies that psychopathology was doomed, psychiatric diagnoses in both DSM-5 and ICD-11 continue to rely exclusively on psychopathology. Their categorical nosology is also challenged by advances in computational psychiatry and an increasingly advocated personalised symptom-based approach to precision psychiatry. The current paper reviews the objectives of psychopathology and nosology, and the recent debate on their role in future precision psychiatry - from guiding neurobiological research by relating neurobiological changes to patients' experiences to giving a framework to the psychiatric encounter. It concludes that contemporary psychiatry does not need less but rather a more differentiated psychopathology and a likely reformed, possibly more dimensional nosology in order to develop approaches that adequately integrate patients' experiences and professional knowledge.

Treating immigrant patients in psychiatric emergency rooms.

We examine whether patient variables (geographic origin, gender, Spanish language proficiency) and subjective clinician aspects in emergency department psychiatric encounters (diagnostic certainty, clinician's comfort level with patient) are associated with diagnosis and the use of coercive measures. Using a descriptive cross-sectional design, we recorded 467 visits (400 foreign-born and 67 native-born patients) in hospital psychiatry emergency rooms (ERs) in Barcelona between 2007 and 2015. We first assessed the association of patient variables and subjective clinician aspects of psychiatric encounters with service use outcomes and with mental illness diagnosis. Fitted logistic models predicted the likelihood of service use outcomes and estimated the propensity of receiving each diagnosis. The null model evaluated the role of patient's geographical origin, while the full model evaluated the additional roles of patient's gender and language, the clinician's assessment of the influence of culture in diagnosis, and clinician comfort with two outcomes: patient's diagnosis and use of coercive measures in the ER. Women were less likely to receive coercive measures or intramuscular medications compared to men. Significant ethnic/racial and gender differences were found in receiving certain diagnoses. Additionally, a patient's lower Spanish proficiency was correlated with a higher probability of receiving a psychosis diagnosis. The clinician's level of diagnostic certainty was also positively correlated with increasing clinician-reported comfort with patient. Overall, ethnic factors and the subjective aspects of psychiatric encounters were found to influence diagnosis and the use of coercive measures. Cultural competency programs and interpreter services within psychiatric ER settings should thus be required.

Effect of long-acting aripiprazole monohydrate on inpatient encounters: A retrospective mirror image study.

IntroductionAntipsychotics improve symptoms associated with schizophrenia and bipolar disorder. To improve medication adherence and decrease the need for hospitalization, many antipsychotics have been developed into long-acting injectable (LAI) formulations. Though mirror-image studies have demonstrated significantly decreased hospitalization rates with LAI use, there is limited data when suboptimal use parameters are present.MethodsA retrospective chart review was conducted on patients who were administered aripiprazole monohydrate long-acting injectable (AM-LAI) in an adult mental health unit. Demographics and AM-LAI use parameters were analyzed descriptively. Endpoints compared the days between encounters pre and post AM-LAI administration and number of inpatient encounters between the 180 days pre and post AM-LAI administration. Effects of AM-LAI on inpatient encounters were analyzed using a Wilcoxon signed rank test with an alpha set to <0.05 for significance.ResultsFifty-eight patients met inclusion criteria. Mean (± SD) age was 39.4 (11.4) years with 55.2% of the sample male. Most patients were diagnosed with schizophrenia or unspecified psychotic disorder and admitted involuntarily. The mean number of days from last admission to the date of initial AM-LAI administration was 109.3 (75.2), compared with 131.3 (69.8) days to next encounter (P = .044) post AM-LAI. Total inpatient encounters were also reduced (P = .004), although no differences in encounters for psychiatric reasons were detected.DiscussionUse of AM-LAI was associated with a prolonged time to next inpatient encounter and reduced total inpatient encounters, however its use failed to demonstrate reductions in psychiatric encounters.

De-othering “schizophrenia”

Do psychiatry and clinical psychology have an “other”? This article critically addresses the clinical-scientific fascination with diagnostic challenges and other psychiatric mysteries, focusing on the example of “schizophrenia,” often seen as the most severe and enigmatic of all mental disorders. Over a century of clinical and scientific discourse on schizophrenia has painted a portrait of something indecipherable at the very foundation of psychiatric inquiry. Despite entrenched beliefs, mounting evidence from both qualitative-phenomenological and quantitative research suggests that the experience of psychosis can be meaningfully understood. Further, there is a wealth of data indicating that persons with lived experience of psychosis can lead self-actualized lives, and new studies have revealed that psychotic experiences are common in non-clinical populations. Yet traditional views of psychosis persist in the face of this mounting evidence. I suggest that the key to de-othering schizophrenia may lie in an emerging body of research on “social defeat,” marginalization, and alienation. More specifically, the experiences and behaviors commonly designated as psychosis arise in social and interpersonal contexts that are distinctly alienating, including the psychiatric encounter. It follows that schizophrenia may not be the elusive empirical object of debates about unintelligibility or “ununderstandability,” but rather a social configuration that is manifest within the deadlock of this debate itself.

Psychopathology-a Precision Tool in Need of Re-sharpening.

Psychopathology is the scientific exploration of abnormal mental states that, for more than a century, has provided a Gestalt for psychiatric disorders and guided clinical as well as scientific progress in modern psychiatry. In the wake of the immense technical advances, however, psychopathology has been increasingly marginalized by neurobiological, genetic, and neuropsychological research. This ongoing erosion of psychiatric phenomenology is further fostered by clinical casualness as well as pressured health care and research systems. The skill to precisely and carefully assess psychopathology in a qualified manner used to be a core attribute of mental health professionals, but today's curricula pay increasingly less attention to its training, thus blurring the border between pathology and variants of the “normal” further. Despite all prophecies that psychopathology was doomed, and with neurobiological parameters having yet to show their differential-diagnostic superiority and value for differential indication, psychiatric diagnosis continues to rely exclusively on psychopathology in DSM-5 and ICD-11. Their categorical systematic, however, is equally challenged, and, supported by advances in machine learning, a personalized symptom-based approach to precision psychiatry is increasingly advocated. The current paper reviews the objectives of psychopathology and the recent debate on the role of psychopathology in future precision psychiatry—from guiding neurobiological research by relating neurobiological changes to patients' experiences to giving a framework to the psychiatric encounter. It concludes that contemporary research and clinic in psychiatry do not need less but rather more differentiated psychopathologic approaches in order to develop approaches that integrate professional knowledge and patients' experience.