is a physician consultant and Certified Peer Specialist in the Department of Psychiatry at McLean Hospital and the Massachusetts General Hospital. She is the author of four books and a blog on managing depression, most recently 

Helping Others With Depression: Words to Say, Things to Do (December 2020)

mental health and wellness virtual coaching practice, opening in July 2021, known as 

and can be confidentially reached through her website at 

Susan J. Noonan, MD, MPH, talks about how hiding the ups and downs of life, and only projecting a fabricated image, can be detrimental to mental health. 

mental health and wellness virtual coaching practice, opening in July 2021, known as Noonan Wellness Coaching, and can be confidentially reached through her website at 

Videos

The B Sides and the Importance of Honesty

The COVID-19 pandemic has exacerbated the psychiatry shortage, particularly in rural areas and small towns. Depression, anxiety, grief, and substance abuse have soared during the pandemic, but 111 million Americans live in a psychiatry shortage area, according to the US Department of Health and Human Services—and the current shortage of 6% is expected to be between 14,280 and 31,109 psychiatrists by 2024.

 The number of physicians entering specialties increased between 2003 and 2013; however, during that same period, the number of physicians entering psychiatry decreased by 0.2%.

Age may serve as an additional factor, as the average age of practicing psychiatrists is 55, the third oldest of all the specialties.

 Research shows that compensation of psychiatrists was a significant factor, particularly for young doctors.

 It is very likely that high-interest student loans in combination with low compensation has caused young doctors to select higher-paying specialties.

Clearly it is essential to have more psychiatrists, but how do we increase the psychiatry workforce to reach all the shortage areas in the country? Although the description of the shortage is clear, the solutions to the problem have not been. Without an intervention, the shortage is projected to continue until 2050. It is time to discuss some short-term and long-term solutions for the problem.

The internal medicine residency is 3 years, and the family medicine residency is 3 years—in contrast, the psychiatry residency is 4 years. With a lot of effort, pain, and imagination, the psychiatry residency could be shortened to 3 years. This would mean that fully trained psychiatrists would graduate every 3 years instead of every 4 years. This 1 change would increase the number of psychiatrists. This 1-year difference would be especially significant for the many young doctors who are carrying high-interest loans from college and medical schools, as a shorter residency would allow them to start paying down on their debt sooner.

If the residency remained 4 years as it is now, the final year of residency could be completely redesigned. That final year could become a year of mandatory clinical rotations in shortage areas, which are mainly rural and small towns. Allowing fourth-year residents—who are nearly fully trained psychiatrists—to provide psychiatric care in shortage areas under academic supervision would be an increase in the psychiatry workforce in areas where it is needed most. Many medical centers are in urban centers, so most residents have little or no exposure to rural or small-town practice. The most optimistic view is that some of the residents who practice in a small town or rural area will like the environment for reasons such as less traffic, lower cost of living, a slower pace of life, and/or lower taxes. Even if only a few residents decided to set up practice in one of these areas, it would be helpful.

The long-term solution would be to build medical schools with a focus on excellent clinical care in some of these rural shortage areas. Many medical centers are the engines of research in the country and in the world. Medical school faculty teach, but also treat patients. Medical students learn how to become doctors by seeing patients with supervision. Residents have clinics and are supervised, but provide a lot of clinical care during their training. Having medical schools nearby would bring a lot of care to the shortage areas, as the best and brightest from those areas may choose to attend medical school in the area in which they live. If these students remain in their hometowns to attend medical school and complete their residency, it would be a tremendous help to the psychiatry workforce. It also might be less expensive for medical students if they do not need to relocate to attend medical school or a residency program.

Although not discussed here, other medical specialties, such as primary care and pediatrics, are experiencing shortages, as well. Along with psychiatry, these 2 are also considered low-compensation specialties. Establishing medical schools in rural areas and small towns could also bring more primary and pediatric care options to patients in these shortage areas.

We have a tremendous amount of data about the psychiatry workforce shortage, and it is important to intervene to discuss ways to decrease it. What is needed now are solutions that can be implemented. The purpose of this discussion is to outline how decreasing the psychiatry residency by 1 year; mandating fourth-year rotations in rural and small towns that have a shortage; and building smaller medical schools in rural communities where the need is so great might serve as effective solutions. As a specialty, we need to have this conversation and intervene to increase the psychiatry workforce. The pandemic is making this more urgent, but it is also important for the future. Psychiatry has to act as soon as possible for the good of the nation.

is a practicing psychiatrist based in Atlanta, Georgia.

Addressing the escalating psychiatrist shortage

. February 12, 2018. Accessed December 15, 2021.
2. Harrar S. 

. Last updated June 2, 2021. Accessed December 15, 2021.

The Silent Shortage: A White Paper Examining Supply, Demand and Recruitment Trends in Psychiatry

 Merritt Hawkins. February 22, 2018. Accessed December 15, 2021.

The Psychiatric Shortage: Causes and Solutions

. National Council for Mental Wellbeing, Medical Director Institute. March 28, 2017. Accessed December 15, 2021.

Articles

The pandemic has worsened the psychiatry workforce shortage. What can we do about it?

Addressing Shortages in the Psychiatry Workforce

I’m revising my med student lecture notes

on Models for the Doctor-Patient Relationship

and the attitudes I want them to master: detached

concern, therapeutic distance, good boundaries.

and I think back to a post-op dairy farmer

who cares for them in a barn a mile away.

For weeks they cry out for family and familiar stalls,

I missed my Girls even more, and one night

It’s a good thing my neighbor has tender fences.

strong enough to hold tight before it bends,

has been writing a poem about his experience of being a doctor every month for the past 24 years in

in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. 

"...barriers that create space for healing placed close enough to hear everyone’s cries of longing and love..."









Tender Fences

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel.

interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a full-time research appointment as a Visiting Researcher at Harvard University, in Cambridge, Boston.

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

“We usually think of what hate does for the individual hated or the individuals hated or the groups hated. But it is even more tragic; it is even more ruinous and injurious to the individual who hates.” -Martin Luther King, Jr.

On Saturday, January 15, 2022, according to the January 16th 

I am grateful to be alive,’ says Colleyville rabbi Charlie Cytron-Walker,

” and consistent with the core principle of Judaism to welcome the stranger, a man was let into Congregation Beth Israel synagogue by the Rabbi when he knocked and asked if the synagogue was a shelter.

 As Shabbat prayer continued, the man clicked a gun, and then held the Rabbi and 3 other Jewish individuals hostage, even as he praised the Rabbi on the live-streamed audio of the service, saying “I bonded with him. I really like him.” The man also said that he himself was going to die, and he did. The additional terrible irony is that Rabbi Charlie Cytron-Walker and his wife are pillars in the area for interfaith dialogue.

As the crisis continued, the suspect was identified as a Muslim. He is a British citizen who immigrated to the United States not long ago. During the hostage situation, he was described as “extremely distressed” and making “political” demands. As information emerges after the event, it seems that he might have chosen this Jewish organization because it was close to a federal prison where he wanted a prisoner freed. This prisoner was convicted of trying to kill US Army officers in 

 and conveyed anti-Semitic sentiment during the ensuing stand-off. The standoff lasted almost 12 hours, and with the active-threat training that the hostages had for such a situation, their maneuvers to flee, and the patience of law enforcement, the hostages fortunately escaped. Given our concern with 

, how the suspect got his gun needs clarification.

The Council on the American Islamic Relations (CAIR), the largest Muslim advocacy group in the United States, condemned the incident as an act of hate: “This latest Anti-Semitic attack at a house of worship is an unacceptable act of evil. We stand in solidarity with the Jewish community. No cause can justify or excuse this crime.”

Omar Suleiman, PhD, a highly respected Dallas-based Imam, also strongly condemned the attack: “…we will be there for our Jewish neighbors as they recover. The perpetrator cannot claim to have acted for any noble cause. He held a beloved faith leader to our community and his congregants hostage with no regard. And those that will use this to stoke the flames of hatred and division will fail as he did, God willing.”

Internationally, similar attacks on houses of worship targeting Muslims, like what happened at the Al Noor and Linwood mosques in Christchurch, New Zealand, on Friday, March 15, 2019; or Christians, like on the International Pentecostal Holiness Church headquarters in Zuurbekom, South Africa on Saturday, July 11, 2020; or the gurdwara Sikh Temple in Oak Creek, Wisconsin, on Sunday, August 5, 2012—all are acts whose apparent aim is to foment social and individual hate, but may also be acts committed by persons who need psychiatric care.

Connected religiously and psychologically to this event, the Jewish Tree of Life synagogue in Pittsburgh also had disastrous loss of member lives on October 27, 2018. This current incident is also liable to be a trigger for that past trauma. So said their Rabbi, Jeffrey Myers, who, in various media interviews after the hostage crisis, also maintained getting mentally stronger through vision of purpose over millennia, combined with ripples of support.

In the United States, as well as the United Kingdom, we are in a time of great conflict and divisiveness that compromises the safety of citizens. Due to projected scapegoating, those who are different usually bear the highest risk of harm.

, an international alliance of social psychiatrists and other mental health professionals of various faiths who have previously written about other conflicts in the Middle East and Afghanistan for 

. Some of the members of this alliance have also edited and written chapters for 3 books published by Springer International over the last 2 years: 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

. SPIRIT welcomes new members interested in helping our cause.

In our mission, we have a moral, ethical, and clinical responsibility to support the survivors and tend to their visible and invisible wounds, as well as to address the ripple repercussions of the traumas as they spread out from the epicenter into society. Although there is interfaith progress, there is still entrenched cross-cultural hate. We try to research the root causes of these harmful and all too common phenomena. Though it is unlikely that psychiatry can often predict something like this by a given individual, we still might find ways to be proactive rather than reactive, try prevention rather than intervention, and instigate systemic change of the adverse social determinants of such mental problems. Psychological autopsies of perpetrators can provide valuable clues to their personal backgrounds, 

, psychological conflicts, and motives. In the case of the Congregation Beth Israel hostage situation, the perpetrator’s brother has already said he had “mental health issues.”

 and mental illness are often a volatile mix. Similarly, security reviews of what happened will hopefully provide increasingly safer guidelines for the future.

We must also reinforce the psychologically beneficial messages embedded in our current holidays. In an unusual confluence, January 17 this year includes the annual Martin Luther King Jr. Day, the Jewish Tu B’Shivat celebration of environmental sustainability, and the inaugural Muhammed Ali’s Day in Illinois celebrating peace. Together, they point the way to social and environmental justice. In the meanwhile, safety and security must be paramount at vulnerable social and political targets, including the current possibility of copy-cat attacks of faith-based communities.

But first and foremost, we must be part of the solution by refusing to be taken hostage to hate.

is a practicing psychiatrist, Providence Healthcare System, Portland,

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is an associate professor of psychiatry at Harvard Medical School and a fellowship site director for Brigham and Women's Hospital. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom.

is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

 is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences.

 is professor emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. 

 is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel. 

 is professor emeritus in psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

 is interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a fulltime research appointment as a visiting researcher at Harvard University in Cambridge, Boston.

 is medical director of the Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

1. 'I am grateful to be alive,' says Colleyville rabbi Charlie Cytron-Walker. 

. January 16, 2022. Accessed January 17, 2022. 

https://www.jpost.com/diaspora/article-692639

2. Council on the American Islamic Relations. CAIR condemns hostage-taking at Texas synagogue, working with local community leaders to learn more and provide assistance. January 15, 2022. Accessed January 17, 2022. 

https://www.cair.com/press_releases/breaking-cair-condemns-hostage-taking-at-texas-synagogue-working-with-local-community-leaders-to-learn-more-and-provide-assistance/

3. Omar Suleiman page. January 15, 2022. Accessed January 17, 2022. 

https://www.facebook.com/imamomarsuleiman

4. Gill D. Synagogue hostage-taker had ‘mental health issues,’ brother says. Daily Beast. January 16, 2022. Accessed January 17, 2022. 

https://www.thedailybeast.com/fbi-identifies-synagogue-hostage-taker-as-british-national-malik-faisal-akram

The recent hostage situation at a synagogue in Texas in indicative of a larger underlying problem. 

We Refuse to Hate

It’s Time for Us to Stop Being So Defensive about Psychiatry

,” I believe that Awais Aftab, MD, has almost entirely mistaken the overall thrust of my article. In fact, the article did not attempt to excuse psychiatrists by tone policing critics, or to deny psychiatrists’ responsibility for the problems of psychiatry. Do these sound like fighting words? I assure you they are not. The fault for such a misunderstanding is my own. By pressing in on the ambiguities of my article, “

It’s Time for Us to Stop Waffling About Psychiatry

,” Aftab has given me a precious opportunity to clarify its purpose.

Before I explain, I would like to extend more than the usual thanks to Dr Aftab for his willingness to deeply engage with my thoughts about public perceptions of psychiatry. We clearly share a passion not only for our profession, but for the patients we attempt to serve. And, in the interest of full disclosure, I should note that I am a big fan of Aftab and grateful for his many articles that have appeared in the pages of 

. I am delighted that he cared enough about my article to refute it.

My article was intentionally provocative. I believe that I and many of my colleagues need a call to arms during a time of great opportunity for mental health in our culture. We need to emphatically defend and affirm the ethical, practical, and scientific legitimacy of what we do as psychiatrists. I hope that many people found the article energizing, whether or not they agreed with my many assertions. It is time for our profession to speak out in a new way.

Nevertheless, the article was—in 1 way—confusing from the very beginning. Its original title was, “It’s Time for 

 to Stop Waffling About Psychiatry” (italics added), which had to be shortened in the editorial process. Thus, my article was in no sense an attack on the critics of psychiatry. It was not addressed to the critics of psychiatry. It was not addressed to the public at large. The article was addressed solely to psychiatrists—more specifically, all psychiatrists who go about practicing as if psychiatric illness were legitimate medical illness. It called on psychiatrists to energetically address distorted impressions and assertions about our field whenever and wherever they arise.

 Aftab, I was not calling on critics to pipe down—rather, I was calling on psychiatrists to speak up. I was not attempting to squelch critics; I was attempting to get psychiatrists to join the debate. I was not hoping that the public would stop hearing about problems with psychiatry; I was hoping that the public would start consistently hearing about the medical legitimacy of psychiatry.

To see Dr Morehead's original article, check out 

It’s Time for Us to Stop Being So Defensive About Criticisms of Psychiatry.

Contrary to appearances, I am not especially worried about the critics of psychiatry. If I had the power to cancel what they have said, I would not cancel a single word. In particular, I have found Aftab’s series of critical articles fascinating and enlightening. With decade upon decade of sustained critique, critics like him have forced our profession to examine and reexamine our assumptions, teachings, diagnoses, and treatments. They have contributed mightily to the improvement of psychiatry. Yet the prominance of such critics, coupled with the relative lack of positive public education about psychiatry, has inadvertently and seriously harmed our patients (as I shall explain below). There is too much criticism in the public ear and not enough education.

It is more than understandable that many people took my stance as being against the critics of psychiatry. After all, I was energetically asserting a pro-psychiatric position and attempting to dispell some of the pervasive 

 extreme critics. But being pro-psychiatry is not, in fact, the same as being anti-criticism. I myself agree with most of the common criticisms of psychiatry, including the pervasive influence of drug companies in shaping our research and practice, the problematic use of the DSM, the underappreciated risks of some of our biological treatments, and the tendency to pathologize and anesthetize normal human suffering.

What is my problem with critics of psychiatry? I have no problem with them. My problem is with the grossly distorted imbalance in our public discussions of mental illness—a balance that is grossly distorted in favor of 

 and against psychiatry. As documented in my article, it is not difficult to find a host of critical and negative articles and books both within and outside of psychiatry, while on the other hand, prominent defenders and explainers of psychiatry are far more rare. Where are our Sigmund and Anna Freuds, Carl Jungs, Karen Horneys, and Karl Menningers of today? Where are the bestsellers explaining psychiatry to the public? Where are the articles in prominent journals and magazines explaining and defending our practices? The critics regularly appear in all of these forums, as well as on YouTube and other internet outlets. Where are the educators and the defenders of psychiatry?

What is my solution to this problem? My solution is not to 

 the knowledge and appreciation of psychiatry as a true medical specialty. My solution is not to paper over criticisms, but to help give the public a wider grounding and more realistic context in which these criticisms can be accurately understood.

Regardless of which “side” gets more press, people outside our field are left in a state of confusion by this vigorous debate. Regardless of whether they hear accurately, members of the general public hear that psychiatry is both hopelessly corrupt and unassaillably good, haplessly inept and unimaginably sophisticated. And it leaves millions in a state of paralysis and irresolvable ambivalence. This state of paralysis and ambivalence is demonstrable from research and almost certainly—in my mind—has had catastrophic consequences.

This is why I painted critics of psychiatry with a broad brush. On one hand, Aftab is right that I was falsely equating careful and thoughtful critics such as himself and Allen Frances with extremists such as 

 and Scientology. One group wants to improve medical psychiatry, while the other wishes to abolish it. But on the other hand, I lumped psychiatry’s critics together in this article for 1 specific reason: because I perceive that the various criticisms are lumped together in our confused public perceptions of psychiatric illness and treatment.

What I mean is this: Those of us who are practicing psychiatrists have a deep knowledge, born of both study and experience, that the following assertions are unshakably true:

Psychiatric illness is legitimate medical illness.

Psychiatric treatment is legitimate medical treatment

Aftab himself endorses such statements in his article. Because we psychiatrists understand these truths, we are neither alarmed nor confused when we encounter critiques of psychiatry. We are not worried that the whole basis for psychiatry is going to be overturned. We are not worried that all psychiatrists are going to be proven quacks or charlatans. We already know better. But the general public, as a whole, does not know better. In fact, even our nonspecialist intelligentsia do not know better. They are likely to be confused and disconcerted by such unanswered criticisms.

When members of the public hear critiques of psychiatry, they do not have a wider and deeper intellectual context in which to receive them. As a result, they may hear accurate critiques in a distorted way. The public is likely to believe either that extreme critiques are true or that moderate critiques are actually supporting extreme points of view. In my opinion, it is most likely that the critiques of psychiatry simply get lumped together into 1 vague, inchoate, and negative impression, which is as much emotional and symbolic as it is articulated and intellectual (

 Information Flow in Public Perception of Psychiatry

I am not asserting that the public is overwhelmingly negative about psychiatry. Instead, I am noting that the public is both highly positive and highly suspicious about psychiatry, and this leads to a state in which half of people with mental illness receive no treatment for it (in any given year),

 and half of those who do receive treatment fail to adhere to or continue with it.

 This state of affairs also leads government bodies to both affirm the necessity of psychiatric care and fail to adequately defend or fund it, while insurance companies claim to cover mental health treatment, but refuse to do so at every opportunity.

Allow me to offer 2 brief case vignettes to illustrate our cultural problem.

“Rob” is a 20-year-old college student who has suffered from depression as long as he can remember. He is ashamed of himself for needing to “depend on a pill,” but reluctantly accepted a prescription for an antidepression from his primary care physician. Rob’s parents do not believe in mental illness and tell him regularly that he just needs to have a better attitude and quit feeling sorry for himself. While hesitating to begin the antidepressant, Rob comes across a news article on a random internet site: “New Study: Antidepressants No Better than Placebo.” He reads the headline, slams the bottle of medications into the wall, and stalks out of his dorm room, leaving the medicines behind.

“Dr Jones” is a psychiatrist who is familiar with the medical literature on 

 and has successfully treated scores of patients with the illness. She also happens to have major depression herself, which has been successfully treated with an SSRI antidepressant. While enjoying her morning coffee, Dr Jones comes across an online news story: “New Study: Antidepressants No Better than Placebo.” She smiles to herself, takes her morning medication, and goes about her day.

Obviously, “Rob” and “Dr Jones” represent the extremes of knowledge about psychiatric illness and treatment—but I do not think either is unrealistic or atypical. The 2 of them illustrate that criticisms of psychiatry have a very different effect on laypersons than on psychiatrists like ourselves. To laypersons who are ambivalent about their ongoing treatment, such public critiques can be deeply unsettling, worrisome, and even undermining of their treatment. To those who suffer psychiatric illness and are hesitating to seek treatment, such critiques can further delay or even prevent treatment from ever occurring. For those in positions of influence with governments and insurance companies, such critiques can weaken their resolve and ability to decisively end unjust and prejudicial practices against those with mental illness.

Once again, I am not opposing criticism. I am not saying that criticism 

 has these harmful effects. Rather, it is 

critique in the absence of context and affirmation

 that proves so harmful to our patients and the wider public. The fault of this does not lie with those who are critical of psychiatry. The fault lies with myself and other psychiatrists who have been quiet and interested observers in the debate rather than vocal advocates for our field.

Because of all this, I would like to call on Aftab and other psychiatrists who have been critical of psychiatry to accept the complementary task of affirming and defending a basic understanding of psychiatry with the general public, including nonpsychiatric intellectuals such as journalists and academics. Some of our most brilliant and energetic psychiatrists in recent decades have been those who challenged our field in fundamental ways. I do not want such psychiatrists to stop challenging our field. But I do say that we badly need them to help us communicate the legitimacy of psychiatry as a medical specialty to those outside our field. They can do both. All of us can do both. And perhaps all of us can agree that it is time to begin this task in a new way.

Allow me to end with 2 quotes, which illustrate that Aftab and I are on the same side. Such statements can also remind us that both critics and defenders of psychiatry are on the same side: the side of those who suffer from mental illness. Critics want to protect patients from the flaws of psychiatry, while defenders want to protect patients from the ravages of mental illness. All of us should endorse both of those goals.

“Dr Morehead and I agree about a lot of things: the fundamental legitimacy of psychiatry as a branch of medicine; the essential role psychiatry has to play in the treatment of mental health problems; that a defense of psychiatry is warranted against egregious and misplaced criticisms; and that the value of psychiatry must be conveyed to legislators, insurers, and the general public.”

Second, I shall ungraciously quote myself from a previously published book: 

“On a deeper level, I am grateful to these critics of psychiatry, and thank them for their work. They care, and they should care. They see problems in our system, and then want to address those problems. They say that this is a matter of life and death, and they are right.”

The way our culture regards mental health is indeed a matter of life and death. It is not something that we as psychiatrists should just passively observe. I am grateful to Aftab and everyone else who cares enough to do something to address this critical issue.

 is a psychiatrist and director of training for the General Psychiatry Residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health, and is author of 

Science Over Stigma: Education and Advocacy for Mental Health

, published by the American Psychiatric Association. He can be reached at 

The author wishes to thank Awais Aftab, Ron Pies, and Mark Ruffalo for their review and comments on an earlier draft of this article.

1.Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53). Center for Behavioral Health Statistics and Quality. 2018. Accessed January 11, 2022. 

https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.pdf

Understanding and managing treatment adherence in schizophrenia.

Persistence and compliance to antidepressant treatment in patients with depression: a chart review.

4. Aftab A. It’s time for us to stop being so defensive about criticisms of psychiatry. 

https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-being-so-defensive-about-criticisms-of-psychiatry

. American Psychiatric Association Publishing; 2021:67.

According to 1 doctor, we all need to communicate the legitimacy of psychiatry as a medical specialty. 

It’s Time for Us to Realize We Are All on the Same Side

Researchers from the Geha Mental Health Center, Mount Sinai, and Cambridge Health Alliance presented on the connections between attention-deficit/hyperactivity disorder (

) and childhood infectious diseases—as well as 

—at the recent 2022 American Professional Society of ADHD and Related Disorders (APSARD) virtual conference.

Beth Krone, PhD, assistant professor of psychiatry at Mount Sinai’s Icahn School of Medicine, discussed ADHD’s relationship to innate and adaptive immunity among children and adolescents with ADHD. She summarized the key markers and processes of the immune system and the gene proxies that demonstrate how the immune system and the nervous system regulate one another, as well as relevant epidemiological literature and studies of health and diseases among individuals with ADHD.

Manor also discussed a population-based case-control study in which she and her colleagues examined the rates of infectious disease in children and adolescents with ADHD compared to a non-ADHD control group with similar demographics. They consulted the electronic medical records of 18,756 patients with ADHD and 37,512 controls without ADHD, all aged 5 to 18, with attention to the exposure categories 

. Results showed that the rates for all 3 exposure categories were significantly higher in the patients with ADHD than in the control group. According to Manor, this means children and adolescents with ADHD experience higher occurrences of childhood infectious diseases, receive more prescriptions for anti-infective medications, and have more visits with physicians and other medical experts, suggesting a clear connection between ADHD and childhood infectious diseases.

Manor described this connection as a major public health issue, especially during the COVID-19 pandemic, stating that the physicians who treat this patient population should keep in mind the vulnerability of these patients to infectious diseases. She also suggested that ADHD should be considered as a comorbidity in children and adolescents with ADHD who also suffer from multiple or frequent infectious diseases.

Margaret D. Weiss, MD, PhD, FRCP(C), medical director of inpatient psychiatry at Cambridge Health Alliance, discussed the connection between ADHD and risk of contracting COVID-19. She stated that ADHD is a specific risk factor for acquiring—and for being hospitalized with—COVID-19 in part because COVID-19 safety guidelines may be difficult for individuals with ADHD to follow, as these individuals may exhibit poor attention, hyperactivity, poor sense of social space, inability to follow instructions, and opposition to rules or mandates. She shared a few important take-home notes: Long COVID may have symptoms similar to those of ADHD and may exacerbate ADHD symptoms; Long COVID may lead to ADHD as a neurological syndrome like encephalitis after Spanish flu; and individuals with ADHD may also be more susceptible to experiencing somatic symptoms of COVID-19. According to Weiss, all these risks may be mitigated in part by effectively treating ADHD.

1. Manor I, Krone B, Weiss M. ADHD, infections, and the immune system. Presented at 2022 APSARD Conference. January 14, 2022.

What are the connections between ADHD, infectious diseases, and COVID-19?

ADHD, Infections, and the Immune System

is a forensic psychiatrist at Cherry Hospital in Goldsboro, North Carolina.

I would like to thank Ronald Pies, MD, for his response, “

Physician-Assisted Suicide: An Egregious Boundary Violation

 It is truly quite a compendium of critiques against physician-assisted suicide. I am not going to rebut his arguments point by point. I respectfully acknowledge that such arguments have been ongoing throughout history.

There are well-documented, strong arguments on both sides. For example, Lydia S. Dugdale, MD, and colleagues

 provide an excellent and succinct summary of positions both for and against physician-assisted suicide. Briefly, they describe how respect for patient autonomy and the compassionate relief of suffering are major arguments in favor of physician-assisted suicide and how unintended harm through suicide contagion and the slippery-slope argument are commonly raised to refute physician-assisted suicide.

 I know Dr Pies is well aware of these arguments. What I am interested in is exploring our common ground.

Is “Death with Dignity” Really Possible?

Medical Aid in Dying Allows for a Focus on Living


Part of Dr Pies’ conclusion states, “Physicians should rededicate themselves to securing state-of-the-art palliative care and supportive counseling for terminally ill patients.”

 I am in complete agreement on this point. In fact, I believe that Dr Pies and I already agree on many points. I absolutely agree we must improve access to care so that everyone receives high-quality health care. I absolutely agree we must treat all underlying mental illnesses and medical conditions. I absolutely agree we must provide pain management. I absolutely agree we must provide relevant psychotherapy and grief counselling. We should also pursue all relevant consultations, hire a death doula, and have conferences with the family and friends. We absolutely should give patients the option to choose to voluntarily stop eating and drinking (VSED). We should provide them with all possible options. And after being provided all the options and receiving all the treatments, I believe there is the patient who will legitimately choose medical aid in dying.

This person is currently invisible in the majority of states across our country. The first step is to acknowledge that they exist. To see them. To believe them. Do we share this common ground, Dr Pies? Do you acknowledge that this person exists?

1. Pies R. “Physician-assisted suicide: an egregious boundary violation.” 

. January 11, 2022. Accessed on January 13, 2022. 

https://www.psychiatrictimes.com/view/physician-assisted-suicide-an-egregious-boundary-violation

One doctor believes there are patients who will legitimately choose medical aid in dying—we just have to acknowledge them. 

Finding Common Ground in This Life 

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

Wouter Kusters, PhD, is a Dutch linguist and philosopher. He is the author of 

; Lemniscaat; 2014). An English translation of 

 was published in 2020 by MIT Press with the title 

A Philosophy of Madness: The Experience of Psychotic Thinking

 (translated by Nancy Forest-Flier). Kusters works as an independent researcher, writer, teacher, and consultant in Gouda, Netherlands. For details, readers can explore his website at: 

 was based on Kusters’ own experience of a psychotic episode in 1987. It won a pair of important prizes in the Netherlands: the Van Helsdingen Award (2004) for the best work on the intersection of philosophy and psychiatry, and the Socrates Award (2005) for the best and most inspiring Dutch philosophy book of the year. After the publication of this book, Kusters made a professional switch, turning from academic linguistics to a career as an independent writer and researcher. He started studying again as an undergraduate philosophy student, during which time he published his second book on psychosis, 

 (Lemniscaat; 2007). Shortly afterward, in the summer of 2007, he experienced his second episode of psychosis, which led to a psychiatric hospitalization, and this provided further impetus for him to continue his work on philosophy and madness. He finished his master’s thesis in philosophy in 2010, which formed the basis of an updated version of 

; Lemniscaat; 2014. His books were a success in the Netherlands and met with widespread acclaim. The publication of the English translation of 

; MIT Press; 2020) has brought his work to the attention of the English-speaking world, and it has prompted a renewed debate on philosophical and phenomenological perspectives on psychosis as well as the relationship between philosophy and psychosis.

 I think it would be prudent for us to begin with at least a few words regarding the nature of inquiry you are undertaking in A Philosophy of Madness, and how that relates to your own experiences of psychosis.

 My book is a philosophical treatise in the tradition of Montaigne’s 

; in the vein of Nietzsche’s and Kierkegaard’s approaches to thought, writing, and life; and with affinities to the early works of the French existentialists, Sartre and Camus. What brings these works together is the focus on philosophical problems of good and evil, life and death, I and the other, without getting lost in academic reasoning for the sake of reasoning itself. It does not present a psychopathological theory, but it does focus on madness as a lived experience, as a concept in philosophy, and as a phenomenon called 

 in psychiatric practice and theory. By stressing the experiential character of psychosis, which I have access to via my own memory, as well as via all kinds of reports and first-person narratives, the direction of my exploration is toward comparable experiences and their expressions. This brings us to all kinds of philosophical thoughts, bordering on reflections around 

, but also to important themes of language, fiction, and nonfiction. For any psychiatrist educated a little beyond the mainstream medical illness, cure, and therapy narratives, it must be clear that my exercise brought me into the small but highly professional and well-informed tradition of phenomenological psychiatry.

You have argued that a philosophical investigation of psychosis provides a better and less prejudicial approach than many mainstream psychological and psychiatric accounts. What sort of prejudices do you have in mind?

 The main prejudice concerns the usual way of approaching psychosis as a negative or a lack and leaving it there. That is, seeing it purely as a deficit, a disorder, a nonfunctioning of some aspect of the mind/brain/body that is supposed to be well-functioning in the individual who is not psychotic. Take for example the idea, found in various kinds of mainstream accounts, that psychosis is some kind of 

. Such a judgement implies that there is good, proper thought, and that psychotic thought can be sufficiently defined as a disturbance, a disordering of this normal, natural way of thinking. It may be said that the disorder is one of jumping too fast to conclusions, or a dysregulation of perceiving salience properly, or an inability to synthesize information coherently, or it is just being plainly illogical. All such approaches share the assumption (the prejudice) that psychosis can be sufficiently defined by what it is not.

The implication of such accounts is that the psychosis is just a disruption that should be suppressed and taken away in order to let the normal flow of experience run again uninterruptedly. It is assumed that there is a healthy, sane part, and an insane, psychotic part, both manifesting themselves in various contexts and intensities. Therapy then consists in identifying and annulling the psychotic part (eg, by medication, by cognitive behavioral therapy, or by so-called 

Wouter Kusters, PhD, uses his experiences with psychosis to better inform his philosophy. What can we learn from him? 