Celebrating 40 Years: Looking Forward

A lot can change in 40 years. And, yet the more things change, the more they seem to stay the same, reflected the 6 editors in chief of Psychiatric Times on the publication’s 40th anniversary.

When he started the publication, John L. Schwartz, MD, hoped Psychiatric Times would be “sort of like a town square,” where his colleagues in the field could come to talk about what was important to them. “I was hoping that it would give psychiatrists information that would be useful to them, both professionally and also personally,” he said in a recent interview. “I thought that psychiatry was getting screwed, and the American people, as a result, were getting screwed.”

Indeed, the past (and present) editors noted the challenges that faced psychiatry and psychiatric clinicians 40 years ago have changed a bit over the years, but many of the issues are basically the same: lack of resources, reimbursement and insurance hassles, stigma and the lack of parity, and the struggle to truly appreciate social determinants of health and the role they play in both psychiatric illness and mental wellness.

So what will move the field forward? According to these experts, refocusing on patient care and the whole patient, collaborating with clinicians in other fields, and producing quality clinical research to support advances are the key to success in the next 40 years and beyond.

First issue. January 1985.

Empowering the Clinician-Patient Relationship

Much has been said over the last 40 years about the intrusion of business and insurance into health care, especially in psychiatry. From our Monitoring Managed Care column to the funny/not funny fictionalized stories of “Dr Ecks” fighting insurance companies seemingly like Don Quixote with his windmills and beyond, leaders in the field and readers have called out challenges and potential solutions in our town square.

In an interview for this issue, Allan Tasman, MD, a former editor in chief, reshared a story of a patient in the early 2000s who asked him to advocate on her behalf to receive therapy from him in addition to the medications for the diagnosis of generalized anxiety disorder. “I called, and the insurance company representative said—I’m not making this up—they said, ‘Dr Tasman, we understand what you’re advocating for your patient, but in this kind of a situation, we don’t reimburse psychiatrists for psychotherapy…. We have a lot of very good social workers on our panel.’ ”

He replied, “Well, that’s fine, but my patient wants to see me. She came to see me specifically. She was referred to me, so she doesn’t want to see anybody else.”

“The representative said, ‘Well, Dr Tasman, would you ever consider getting a consultation from a senior psychiatrist in your city to see whether your treatment plan is, you know, appropriate?’ ” Ironically, Tasman was the senior person in the area, and often saw referred patients for second opinions. Yet, here was a nonmedical individual dictating appropriate patient care to him.

“Many of my colleagues are basically just doing medication management now,” Michelle Riba, MD, a former deputy editor in chief, told Psychiatric Times. “And, as we’ve written about in the past, [successful treatment] really needs psychotherapy and medication and maybe another treatment modality. To think that medication alone will help patients most of the time, doesn’t really work.”

“You really have to understand the patient and follow the patients over a course of time,” she added, pointing out the importance of psychiatric clinicians taking back their role in patient care. “It’s easy to take out the prescription pad and just add medications. It’s very much more important to listen to the patient and determine what is going to work and follow the patient to make sure that they’re taking it in the proper way and that it’s really impacting positively on their psychiatric condition.”

“We in psychiatry gave the power to determine the length of a psychiatric visit in the late 1990s and early 2000s to insurance companies and administrators whose agendas are more financial than patient care,” John J. Miller, MD, current editor in chief, lamented in an interview. Miller has criticized the 15-minute med check that has been imposed on psychiatrists in many of his Letter From the Editor articles since he took the reins in 2019. He routinely encourages clinicians to extend that time, including a previous suggestion for the “16-minute med check” in attempts to better assess and support patients.

Probably a result of this push by insurance, psychiatry has become less invested in psychotherapy—both as an aspect of psychiatric training and as a component of professional practice, Ronald Pies, MD, Psychiatric Times’ second editor in chief, added to the discussion. “That’s not to say that psychiatry has ‘lost its mind’.¹ But, in my view, it is at risk of losing its soul if current trends continue,” he said. “We urgently need to protect and preserve our investment in psychodynamic theory, a broad biopsychosocial understanding of mental illness, and our role as ‘doctors of the soul.’ ”

A Bio-Psycho-Social-Spiritual Model of Psychiatry

As Psychiatric Times was launched, the field celebrated biological psychiatry and “the decade of the brain,” leaving psychoanalysis behind in its wake.

“The 1990s was a period of great optimism that the mysteries of the brain/mind could be resolved by meticulous study of receptors and circuits. However, it appeared that some of these aspirations ultimately soared too high and close to the sun,” former editor in chief James L. Knoll IV, MD, told Psychiatric Times. “As a pre-med student, I was swept up into this enthusiasm. I spent untold hours in the lab measuring dopamine receptor binding in frogs.”

As the only EIC forensic psychiatrist, Knoll had recognized the need to understand the bigger picture, evaluate issues such as social determinants of mental health, and look beyond just biological psychiatry.

Knoll pointed to the writings of his colleague Jacob M. Appel, MD, JD, MPH: “A golden opportunity exists to return psychiatry to refocus on its roots as a helping profession.”²

“This is why, well over a decade ago, I chose as my EIC opening salvo a “return to the path,” he said.³ “I stressed the fact that many of our patients have been relocated. Carceral settings, particularly jails, now house more persons with serious mental illness than do psychiatric hospitals.⁴ Thus, I suggested a return to the original ideals of our path—the care and well-being of persons suffering in our ‘new asylums.’”

Tasman likewise has been an advocate of investigating and addressing social determinants of mental health, discussing them when he was editor in chief and later writing an in-depth article for Psychiatric Times before most other psychiatric publications. “When I started as editor, people were just beginning to talk about the impact of social determinants of health and mental health,” he said. “But it was just beginning. And DSM IV actually had the 5-axis system. There was an entire axis devoted to assessing potential social determinants.” Unfortunately, that system was eliminated with the DSM-5, much to the disappointment of many clinicians and leaders in the field.

Despite this potential setback, Pies noted that the field has advanced overall in finding a balance. “Psychiatry has become both more circumspect and more nuanced in some of our claims, especially with respect to the so-called biological revolution in psychiatry, made famous in Dr Nancy Andreasen’s 1985 book, The Broken Brain,” he said. “Compared with the gee-whiz enthusiasm of 1985, the profession has come to realize that there are no simple biological explanations for the major psychiatric disorders, nor is a purely biological approach to psychiatric illness helpful or effective. We have come round to the realization that the most serious illnesses we treat—schizophrenia, bipolar disorder, etc—are quite heterogeneous and overdetermined, probably resulting from the complex interplay of genetic, epigenetic, neurochemical, environmental, and psychosocial factors.

“I have always viewed psychiatry as a “bio-psycho- social-spiritual” discipline—put another way, as one of the ‘human sciences,’ ” he added.

Advancing the Science of Neuropsychiatry

Fortunately, advances over the last 40 years have yielded a better understanding of psychopathologies and etiologies, resulting in increased and better treatment options.

Tasman credited the simultaneous improvements and developments in technology for the successes. “People could do sophisticated kinds of analyses, not only on impact on neurotransmitter systems, but also on potential genetic influences,” he explained.

“For example, when the SSRIs came out, I was one of the people who thought it may not be these neurotransmitter systems that are really making the difference—it’s potentially some modification of genetic expression or inhibition,” he said. “Well, nobody could figure that out in those days, because the technology didn’t exist yet…. As the technology to study brain activity and the impact of molecules on brain functioning improved, I think diagnoses and treatments are getting more and more sophisticated.”

Miller agreed. “There has been remarkable progress in the basic science of neuroscience, which has led to a quantum leap in understanding how the brain functions as an organ and has led to many novel treatments that improve outcome and decrease adverse effects,” he said. “These advances include psychopharmacology, neuroimaging, transcranial magnetic stimulation, pharmacogenomics, and a more refined differential diagnosis with improved and more precise diagnostic tests.”

Knoll shared that one of the greatest advances of the last 40 years was the advent of the second-generation long-acting antipsychotic injectables, which “has improved the mental health and quality of life of countless patients.” Nonetheless, he noted there is more work to be done. “I believe the field is in desperate need of renewed clinical research efforts, guided by strong ethical principles and conceived of by psychiatrists in the trenches who are primarily motivated to alleviate our patients’ suffering.”

Yet with increased pharmacological options for addressing bipolar disorder, sleep, mood, and schizophrenia, come the dangers of polypharmacy, Riba said, adding it is important for the field to advocate for the “judicious use” of medications.

The Next 40 Years and Beyond

“I think the field is at a very critical inflection point,” Pies said. Much like the popular trope based on the Chinese characters for crisis, he added “psychiatry is facing both danger and opportunity. The danger is that psychiatrists will yield to malign economic forces that truncate our professional role, by turning us into mere prescribers, chained to the wholly inadequate 15-minute med check.”

“On the other hand, we have the opportunity to become a truly biopsychosocial—and yes, spiritual—healing profession, grounded in science but steeped in the humanities,” Pies said. “That may sound like pie in the sky in today’s world of fragmented health care and merciless cost-cutting, but I think the goal is achievable if we find the courage and fortitude to pursue it.”

Perhaps that’s why Psychiatric Times continues to be a much-valued resource and forum. “Psychiatric Times serves as a useful alternative ‘voice’ to that of official organizations, such as the American Psychiatric Association,” Pies commented. His successor in the EIC role, Knoll, added, “Today, as in the past, Psychiatric Times plays a critical role in promoting an open psychiatric forum that values intellectual freedom and diversity.”

For the psychiatrist currently at the helm, Miller is dedicated to inviting conversations, debates, resources, and diverse voices to the clinical discussions, meeting Schwartz’s ideal of supporting psychiatric clinicians professionally and personally.

“Psychiatric Times provides a unique publication that serves a different purpose for each of our readers. It exposes readers to a broad range of topics, ideas, and updates that would be hard to find in any single location and values the experiences and contributions of everyday clinicians,” he said. “My hope is that the 40-year culture that Dr Schwartz created will continue over the ensuing decades.”

How does Schwartz, who sold the publication years ago, feel about Psychiatric Times after all these years?

“I’m quite thrilled,” he said. “When I started Psychiatric Times, somebody I knew in the publishing world who was very successful said to me, ‘You know, don’t get too excited. The average length of survival of new publications is less than 2 years.’ Here we are 40 years later.”

“Even now, I get the Times in the mail, and as soon as I get it, I sit down and go through it and look at it and think, ‘Gee, that’s interesting,’ ” Schwartz added. “I’m very thrilled to see the publication looking so good, having so many good things in it.”

References

1. Reiser MF. Are psychiatric educators “losing the mind”? Am J Psychiatry. 1988;145(2):148-153.

2. Appel JM. Helping vs. preventing harm: reversing mission creep in psychiatry. Arch Psychiatry. 2024;2(1):59-62.

3. Knoll JL IV. Psychiatry: awaken and return to the path. Psychiatric Times. 2011; 28(5):1-4.

4. Dvoskin JA, Knoll JL, Silva M. A brief history of the criminalization of mental illness. CNS Spectr. 2020;25(5):638-650.