A Social Psychiatrist Looks Back on 2024 and Forward to 2025: Hurry Up and Slow Down!

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It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity…

– Charles Dickens, A Tale of Two Cities (1859)

That is how I see the year in review and the prospects for 2025—in psychiatry as in society, we are living in a time of contrasts and extremes.

Syndemics: The Social Nature of Epidemics

Historians note that pandemics are more disruptive and transformative than wars or revolutions. Now that we have weathered the worst of the COVID-19 pandemic, we can understand those impacts better by the more accurate and descriptive name of syndemic, coined by American medical anthropologist Merrill Singer, PhD. Richard Horton, OBE, FRCPCH, FMedSci, in The Lancet observed that the term plague does not capture our new reality¹:

These conditions [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and non-communicable diseases (NCDs)] are clustering within social groups according to patterns of inequality deeply embedded in our societies. The aggregation of these diseases on a background of social and economic disparity exacerbates the adverse effects of each separate disease. COVID-19 is not a pandemic. It is a syndemic.

What should concern us most are the NCDs of the COVID-19 syndemic that piggyback on preexisting patterns of social and economic disparities. One of the lessons learned was that with limited resources, we should target the most vulnerable populations instead of shutting down the whole society. We are also now seeing the consequences of both the COVID-19 syndemic on vulnerable populations and the attempted solutions—confinement and social distancing.²

We are living with the midterm impacts in child psychiatry along with social, economic, and political impacts on the rest of society.^3,4 Children and youth that were already well-off and healthy mostly continued in health.⁵ Those that were not, including children with anxiety and neurodevelopmental disorders, have not all bounced back. My child psychiatry clinic is filled with kids who were schooled at home and now have great difficulty returning to the classroom socially, academically, and emotionally.^6,7

Along with redefining the nature of pandemics in broader terms that recognize the social determinants of health (SDH), we need to revisit our assumptions about development, risk, and resilience. Looking forward, the challenge is to avoid being reassured by better outcomes in community patterns in health and social care among well-resourced populations or panicked by poor outcomes among the disadvantaged. Expecting both, we should continue to study what protects or predisposes vulnerable populations and target those who need our limited resources the most.

Is There a Child Health Care Crisis?

When Dan Offord, MD, a pioneer in child psychiatric epidemiology, was asked in the 1990s by the Premier of Ontario how many children in Ontario had a mental disorder, he responded, “Tell me how much money you want to spend and I’ll give you a number.”

There was much talk this year about a child mental health crisis. The 2024 State of Mental Health in America Report expresses concerns about a “polycrisis,” or high levels of youth distress while access to care is limited: “The nation’s youth continue to present cause for concern. One in 5 young people from ages 12 to 17 experienced at least 1 major depressive episode in the past year, yet more than half of them (56.1%) did not receive any mental health treatment. More than 3.4 million youth (13.16%) had serious thoughts of suicide. More than 45 million adults (17.82%) and 2.3 million youth (8.95%) are experiencing a substance use disorder.”⁸

Is this crisis real or just a perception? Is it a separate epidemic or a cascading consequence of the COVID-19 syndemic? The answer is: It depends—on the assessment methodology and the definitions of health. Is it a result of an explosion of mental, relational, and social suffering or an access to care and a service delivery problem? The “prevalence inflation hypothesis”⁹ warns that we may be overdoing it, that self-labeling youth inflates levels of distress and negatively impacts their coping skills, while public awareness campaigns may fuel their problems rather than alleviating them.

What we do know is that SDH¹⁰ and adverse childhood experience (ACE)¹¹ studies demonstrate the critical relationships among stress, trauma, early childhood experiences, and health outcomes. The analytical tools these studies provide are teaching us that we need new maps for the post-syndemic reality.

Loneliness

“[T]he essence of human tragedy [lies in] loneliness, not in conflict”

—Frieda Fromm-Reichman, “Loneliness”¹²

Similar questions may be posed about the loneliness epidemic. Although researchers have been discussing this issue for more than a century, loneliness was officially declared an epidemic by the Surgeon General this year. According to some experts, social media and digital technology have increased the sense of isolation enormously, paradoxically, especially when the goal is to maintain relationships.¹³

William James, MD, the brilliant physician and philosopher who founded American psychology at Harvard University, wrote in his Principles of Psychology (1890) that: “No more fiendish punishment could be devised…than that one should be turned loose in society and remain absolutely unnoticed by the members thereof.”¹⁴ That is still very meaningful for many of us but some are retreating into an interior digital space with the illusion of relationship. As one cartoon joked, a widow bemoaned the lack of people at her late husband’s funeral, saying he had thousands of Facebook friends!

Psychotherapy: The Return of the Repressed

One of the most resonant phrases that Freud coined, “the return of the repressed,” goes to the heart of psychotherapy and psychodynamic psychiatry. It means that painful experiences persist even when we ignore them. Like the first law of thermodynamics, in psychodynamics there is no dissipation of emotional energy.

In terms of trends, after the “standard model” of my generation—from the mid-60s to the 80s, with the triad of DSM, the biopsychosocial model, and psychodynamic psychiatry—we had the decade of the brain and neuroscience in the 1990s. The biopsychosocial model increasingly become “bio-bio-bio,” as Allen Frances, MD, has said.¹⁵

This leads us to the bad news: We have morphed into evidence-based medicine (EBM) and diversity, equity, and inclusiveness (DEI) without a consensus on a unifying or general theory or treatment model but a preponderance of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) imposed by managed care.¹¹ One consequence of EBM led to the elimination of the multiaxial system of diagnosis, ostensibly due to poor reliability of some of the axes, which effectively screened out much of the “psycho” (at least partly addressed in Axis II) and most of the “social” (Axes IV and V) in biopsychosocial.

Although visionaries in psychiatry believe that the social should be self-evident and applied in all areas of psychiatry, we know that if we do not have tools to identify and measure the SDHs10 and ACEs,¹¹ they tend to be ignored. Just as we were debating adding family and cultural axes, we lost the multiaxial system (DSM-III and IV) altogether for the dimensional approach of DSM-5. Axes IV (Psychosocial and environmental factors affecting the person)and V (Global assessment of functioning) captured the social aspects of psychiatry. What we need now are instruments or procedures to operationalize SDHs and ACEs to add to our evaluation strategies. And that is something to look forward to in 2025.

Thankfully, there is good news: There is an emerging trend among psychiatrists in training and a resurgent caucus at the American Psychiatric Association (APA) urging a return to psychotherapy, despite the downward trend reported in the literature.¹⁶ This movement is perfectly represented and led by Dilip V. Jeste, MD, who chaired the APA Task Force on SDMH and is now director of the Global Research Network on Social Determinants of Mental Health and Exposomics, and president-elect of the World Federation for Psychotherapy. Jeste brings his formidable research background to bear on the SDMH paradigm, expanding it to include exposomics, or the study of all the exposures that impinge on health. This emerging body of research will be subject to translational research turning basic research into clinical interventions.¹⁷ What a diverse intersection of interests and leadership for our field and a potential integration of EBM and SDMH with psychotherapy!

Interdisciplinarity

Beyond guild issues, serious work psychiatry and mental health are done in an interdisciplinary way. The best work in our field is organized not around one or other of the clinical professions or research disciplines, but around problems or approaches. However, we still need more crosstalk and to integrate social sciences and the humanities into research, teaching, advocacy, policy-making, and practice.

Philip R. Muskin, MD, MA, in an interview at the 2024 APA Annual Meeting demonstrates the value of training in psychology and psychotherapy for psychiatry. He emphasized 3 vital take-home messages¹⁸:

• “Collaborating with rather than treating patients”: It is time to think of patients as partners.
• “Inclusiveness” is about reaching out to people.
• “Access to care”: If psychiatric epidemiology and the global health movement have taught us anything, it is the treatment gap. As we all know from our practices, we have a resource and access problem. There are not enough people—psychiatrists and others.

My answer is if we cannot do everything, we must do more to target the vulnerable who are at risk, not the entire population. Target our interventions more precisely: another lesson we must learn from the COVID-19 syndemic.

Beyond 2 Cultures

One of my favorite political cartoons by David Sipress in The New Yorker has 2 people giving a weather report: “That was Brad with the Democratic weather. Now here’s Tammy with the Republican weather.” So, it has come to that!

In Britain in the late 1950s, noted physicist and novelist CP Snow gave a lecture on the 2 cultures of science and the humanities, arguing that they could no longer understand each other. While there has been a call for a third culture by John Brockman,¹⁹ this binary division has increased and, if anything, poisoned the entire society with a “pernicious polarization.”²⁰

Divisiveness shows up not just in politics and professions, but also runs rampant throughout society. I notice that both politicians and professionals mimic commercial advertising. People communicate in “talking points.” Things are simplified and both ideas and people are used “transactionally.” This is a troubling word: transactional, or “relating to the conducting of business, especially buying or selling.”Talking points are selling points where everything becomes a sales pitch rather than a dialogue.²¹ You feel buttonholed, each new psychiatric prophet grabbing you by the lapels to tout the latest panacea—CBT, now the new and improved DBT. Not just PTSD, but complex PTSD!

Festina Lente—Hurry Up and Slow Down!

A final good news/bad news contrast. The bad news is that individuals are not going to meetings as much; the APA had a loss with its annual meeting in NYC this year. This was partly an ongoing impact of COVID-19 since everyone got used to attending meetings online. The good news is that, with a diversity of approaches available, people are thinking for themselves and making informed choices about what to do in their practices.

Here is what I have come to believe about meeting and communication among ourselves. I trust the audience will take something useful from what I propose and sift out the rest. Against a common prejudice about groups and groupthink, the best antidote to the artificial authority of privileged views is open communication.

Along with asking that individuals declare their conflicts of interest and commitments to EBM and DEI, I would like to request 2 more things:

1. That no talk take up more than 50% of any presentation, leaving half the time for audience discussion.
2. There should be fewer talks at meetings with more time allotted for real exchange and integration of knowledge and skills.

In other words, 10-minute TED talks are dumbing down the culture of psychiatry, like everything else. A psychiatry for dummies? Psychiatry is not for dummies! We need to be quick-witted but thoughtful in the adaptation of new studies and tools. As the Latins put it, festina lente. Hurry up and slow down! For more background on slow thought and slow psychiatry, see my column²² and my slow thought manifesto.²³

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry and addiction medicine at the University of Montreal. He is also clinical professor of psychiatry and behavioral health at The George Washington University and president of the World Association of Social Psychiatry (WASP). Di Nicola has received numerous national and international awards, honorary professorships, and fellowships. Of note, Di Nicola was elected a Fellow of the Canadian Academy of Health Sciences (FCAHS), given the Distinguished Service Award of the American Psychiatric Association (APA), and is a Fellow-Elect of the American College of Psychiatrists (FACPsych). His work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Di Nicola’s work includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021).

References

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