H. Steven Moffic, MD, has traveled all over the world with his wife Rusty. In his travels, he has collected an array of masks that reside in his office and around his home. 

 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 

Videos

One doctor travels around the world, building his mask collection. 

The Masks We Wear

is the Semmes Foundation Distinguished University Chair in Neurobiology at the University of Texas, 

The big news in Alzheimer disease (AD) is the Federal Drug Administration’s 

. It is the first-ever disease-modifying AD treatment, which works by targeting amyloid beta plaques in the brain.

But its approval has also generated controversy. Three members of the Federal Drug Administration’s advisory committee have resigned, arguing that evidence for the drug’s efficacy was not strong enough to merit 

George Perry, PhD, is among the skeptics. In this Mental Health Minute, he raises questions about the drug’s mechanism. He has long been skeptical of what he calls 

Do you think aducanumab will be safe and effective for your patients? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

The FDA approval of aducanumab has given hope to millions of patients with Alzheimer disease—but will it live up to the hype?  

A Skeptical Look at Aducanumab

June is Posttraumatic Stress Disorder (PTSD) Awareness Month. One psychiatrist is dedicating a portion of the proceeds from his new book, 

 program—in the hopes of curbing US military veteran suicides.

, Norman E. Rosenthal, MD. Dr Rosenthal is a world-renowned psychiatrist and researcher, most widely known for defining seasonal affective disorder (SAD) and pioneering the use of light therapy as treatment.

Psychiatric Times (PT): Tell us about your book Poetry Rx

and what inspired you to address PTSD in veterans in this way.

 Over my years as a psychiatrist and long-time poetry lover, it has become increasingly clear to me that poems can heal, inspire, and bring joy to our lives. Some time ago it occurred to me that this is our goal as psychotherapists, doctors, and healers. Over time I accumulated many poems that have this potential. Finally, I felt I had a way of organizing these poems so that they could deliver on the therapeutic promise of poetry.

PT: Your book features a poem by Russian poet Anna Akhmatova. Why did you choose this particular piece? How does is speak to the overall meaning of your work? Is there a particular poem that stands out to you as the most important?

 I first encountered this poem in the web-based Favorite Poem Project, a brainchild of former poet laureate Robert Pinsky. 

 by Anna Akhmatova was chosen by Georgia Tech professor of cognitive science, Nancy Nersessian, PhD, in memory of her brother, who was a Vietnam veteran traumatized by his wartime experiences. The second stanza of Akhmatova’s poem goes as follows:

Dr Nersessian, whom I interviewed for the book, wondered whether it would have been helpful to her brother to kill the memories of the war that haunted him. In Akhmatova’s poem, we see that this was not a helpful strategy for her. As I discuss after presenting the poem, the intrusive memories of PTSD are often treated by encouraging those who suffer to actively think about their traumatic memories in ways that decondition their painful responses.

In “The Sentence” we also see an excellent depiction of dissociation, which is valuable for individuals suffering from PTSD to understand. It is easier for clinicians to focus on the dramatic symptoms of PTSD like nightmares and flashbacks and to overlook the emotional costs of shutting down one’s emotional dealings with others, which can severely impoverish the life of the individual with PTSD.

Another poem in the book also highlights the problem of PTSD: 

 by Gwendolyn Brooks, in which the poet describes 7 young men in a pool hall. Brooks describes them as lurking late and thinning gin, amongst other behaviors that suggest young men looking for trouble. The last line of this short verse packs a powerful punch: “We die soon.” That poem was brought to my attention by John, a young man in Boston, who was suffering from PTSD after hearing about a violent attack on a close relative. To numb the painful symptoms of PTSD, John started drinking too much, taking substances, and filling his hours with fantasies of revenge. An English teacher saw he was having problems and suggested he try reading and writing poetry. John came across “We real cool” and was impressed by how it described the rapid cascade by which young men can fall into trouble and end up dead. He is now in recovery and credits poetry in general, and “We real cool” in particular, with saving his life.

PT: What impact do you believe poetry has on mental health?

 Mental health involves having the skills to navigate all phases of life. 

 is organized into categories that engage different challenges that we encounter along life’s hopefully long journey. From loving and losing (the first section), to aging and dying (the fifth and last section), the book provides poems that offer specific comfort and advice at all stages. In between these 2 bookends are 3 other sections: 1. Responses to nature; 2. Aspects of the human experience; and 3. A design for living and the search for meaning. After each poem I provide a short essay, which basically discusses what the poem is all about, followed by several specific take-away lessons, ending with a short bio sketch of the poet that illustrates the connection between poet and poem. Individually, the poems offer specific guidelines on specific issues. Collectively, the anthology provides a guide to living a good life and enjoying poetry along the way.

PT: Is creative writing an outlet for you? How has it personally helped your mental health?

 Creative writing has been terribly important to me. There is great joy in being able to say things in exactly the way you want to and have it come out as beautifully as possible. An even greater joy is to touch the reader in a meaningful way by offering descriptions, ideas, and insights that stimulate, comfort, enlighten, delight, or all of the above. I get pleasure and fulfillment in writing and in the response of my readers. During the pandemic when there was so much isolation and deprivation, not to mention fear and loss, the poems themselves and writing about them were a great boon. Here is how I describe the effects they had on me in the closing remarks of my book:

As I think about the poems in this book, what I have learned from them, and how they might help people, certain images come to mind. At times the poems have seemed to me like precious stones, refracting the ambient light and filling the room with color. At other times, they have been like lamps, illuminating the dark caverns of the mind, revealing new ways to understand old mysteries. Beyond these images of delight, however, the poems have felt like medicine or balm, and their poets like healers, speaking to us across the ages. It has been an honor to interpret these great works through the lens of one who has spent my career trying to understand and heal the troubled mind, and help people reach the outer bounds of their potential. I believe that these poems have the power to heal, transform and enliven. Perhaps some of them have done so to you. If not, I hope they have at least offered a brief reprieve from an all-too-often troubled world.

PT: A percentage of proceeds of your book go to the David Lynch Foundation’s Resilient Warrior program.

Can you tell us about the program and what it means to you?

 The David Lynch Foundation is devoted to teaching Transcendental Meditation (TM) to groups of individuals who cannot afford to pay for their own tuition. One such target group consists of veterans with PTSD, of whom an estimated 21 commit suicide every day. Even those who do not meet such a tragic end nevertheless suffer badly.

At one point in my career, when I was CEO of a clinical trials organization, I used a small grant to do a pilot study on the effects of TM on veterans with PTSD and was impressed at the powerful benefits they experienced. Later, I collaborated on a large (210 subject) controlled study of veterans at the San Diego VA, which found that TM was as effective as a standard therapeutic treatment and superior to an active control. These experiences have led me to believe that providing free TM tuition to veterans with PTSD is an excellent way for me to allocate the funds I set aside for charitable donations.

PT: You’re known for your work on the development of light therapy for seasonal affective disorder (SAD). Do you consider yourself more research-oriented or creative-minded?

That seems to me like a misleading dichotomy. I think that a good researcher must be creative-minded, has to put together unexpected pieces of data, chase up hypotheses that seem most likely to yield fruit, assemble a team creatively, and analyze the data creatively. In other words, the best research involves a great deal of creativity at multiple levels. But not all creativity uses the scientific method. Literature, music, and art are creative without using formal scientific methods, such as controlled studies. I always remind myself that our research on SAD began with 1 patient who reported seasonal variations in depression that he hypothesized were driven by changes in environmental light. That led me to think of my own winter lows after immigrating to North America, which I had never suffered in South Africa, my sun-filled native country. We did not leave matters at the anecdotal level, however, and went on to do the scientific work necessary to defining the syndrome of SAD and exploring the beneficial effects of light therapy in its treatment. We collected a large number of individuals who complained of winter depressions, defined the syndrome of SAD, and designed controlled light therapy and other studies exploring which aspects of light therapy were important and how bright light affected the psychobiology of our patients.

, describes a hypothesis that is still at the anecdotal level, based on the subjective experiences of individuals both in sickness and in health. Once again—as with seasonal changes—I have experienced these beneficial effects myself and seen them in my patients, with various poems having specific effects. These observations do not readily lend themselves to the scientific method, so I thought that before such methods are developed, I will share them at the anecdotal level in the hope that they will prove helpful and enjoyable to readers. At this stage, you might consider it more creative-minded than research-oriented.

To answer your question, I enjoy moving fluidly between these different ways of thinking.

PT: What recommendations do you have for doctors who are treating veterans with PTSD?

 There are many established treatments for PTSD. Some involve exposure to the traumatic triggers, either directly (as in Prolonged Exposure), or in the context of a cognitive approach (Cognitive Processing Therapy), or eye movement desensitization and reprocessing. Other approaches do not employ exposure-based techniques, such as interpersonal psychotherapy or TM. I would like to think that someday poetry will also be employed to help patients with PTSD as an ancillary treatment.

PT: June is PTSD awareness month. In your experience, what’s the most important thing for practicing clinicians to know about veterans with PTSD?

 Please be aware how much they suffer. Many of these veterans are not used to talking about their feelings. They feel ashamed about their symptoms, which they often perceive as weakness. They need encouragement and support. It is useful for PTSD patients to associate with other veterans with PTSD, who have undergone therapy for the condition and experienced the rewards. 

PT: Besides the Resilient Warrior Program, are there any other veteran resources you’d recommend?

-National Center for Post Traumatic Stress Disorder. 

-National Alliance on Mental Illness (NAMI) 

Articles

This renowned psychiatrist is donating a portion of the proceeds from his book sales to help stop US military veteran suicides. 

Poetry for PTSD and Preventing Suicide

Ahead of June 17—the 50th anniversary of President Richard Nixon’s declaration of the “war on drugs”—2 US representatives, Bonnie Watson Coleman (D-NJ) and Cori Bush (D-MO), revealed the 

 (DPRA), alongside their strategic partner Drug Policy Alliance (DPA).

 The aim of this bill is manyfold: to end criminal penalties for drug possession at the federal level; to shift regulatory authority from the Attorney General to the Secretary of Health and Human Services; to expunge criminal records; to provide for resentencing; and to reinvest in alternative health-centered approaches.

“Every 23 seconds, a person’s life is ruined for simply possessing drugs. Drug possession remains the most arrested offense in the United States despite the well-known fact that drug criminalization does nothing to help communities, it ruins them. It tears families apart, and causes trauma that can be felt for generations. The drug war has caused mass devastation to Black, Latinx, Indigenous and low-income communities and today we say, ‘Enough is enough!’” Queen Adesuyi, Policy Manager for the Office of National Affairs at the Drug Policy Alliance said to the press. “We will not be subjugated any longer by an offensive that was created solely with the purpose of ‘disrupting’ our communities. This bill gives us a way out—a chance to reimagine what the next 50 years can be. It allows us to offer people support instead of punishment. And it gives people who have been harmed by these draconian laws a chance to move forward and embrace some semblance of the life they have long been denied.”

The DRPA bill also intends to eliminate many of the life-long consequences associated with drug arrests and convictions: denial of employment, public benefits, immigration status, drivers’ licenses, and voting rights. Furthermore, the bill incentivizes state and local governments to adopt decriminalization policies—if they do not, their eligibility to receive funds in the Byrne and COPS grant programs will be limited.

“The United States has not simply failed in how we carried out the War on Drugs—the War on Drugs stands as a stain on our national conscience since its very inception,” said Congresswoman Bonnie Watson Coleman. “Begun in 1972 as a cynical political tactic of the Nixon Administration, the War on Drugs has destroyed the lives of countless Americans and their families. As we work to solve this issue, it is essential that we change tactics in how we address drug use away from the failed punitive approach and towards a health-based and evidence-based approach.”

Congressman Cori Bush also shared her thoughts on the bill, relating it to her personal experience: “Growing up in St. Louis, I saw the crack-cocaine epidemic rob my community of so many lives. I lived through a malicious marijuana war that saw Black people arrested for possession at three times the rate of their white counterparts, even though usage rates are similar. As a nurse, I’ve watched Black families criminalized for heroin use while white families are treated for opioid use. And now, as a Congresswoman, I am seeing the pattern repeat itself with fentanyl, as the DEA presses for an expanded classification that would criminalize possession and use. This punitive approach creates more pain, increases substance use, and leaves millions of people to live in shame and isolation with limited support and healing. I’m proud to partner with Congresswoman Watson Coleman on legislation to end criminal penalties for drug possession at the federal level and repair harm in Black and brown communities. It’s time to put wellness and compassion ahead of trauma and punishment.”

 conducted by Bully Pulpit Interactive (BPI) and released by the DPA last week, 66% of American voters were in support of removing criminal penalties for drugs and reinvesting resources into treatment and addiction services. About 65% support ending the war on drugs, and 64% support repealing mandatory minimum sentencing for drug-related crimes.

“A different reality—one where we treat people who use drugs with dignity and respect, and one where drugs are no longer an excuse for law enforcement to surveil, harass, assault and even kill Black, Latinx and Indigenous people—is 100% possible, and these results clearly prove that,” said Kassandra Frederique, Executive Director of the Drug Policy Alliance.

The DPA has consistently advocated for drug decriminalization as a critical first step in ending the war on drugs, as is evident in some of its 

, Thomas R. Kosten, MD, Jay H. Waggoner Endowed Chair and co-founder at the Institute for Clinical and Translational Research, said this on the new bill: "This Drug Policy Reform Act of 2021 is a great contribution to more equitable treatment rather than prosecution of drug users, while preserving some of the deterrence needed for reducing drug trafficking and its black market economy and associated crime. Making substance use a health issue and not a criminal issue is brilliant and long overdue. These actions can also start to empty our over-crowded and often inhumane prisons, which are over-populated with low level drug users and minorities. The Commission process to determine a benchmark amount of each drug type for personal use is another brilliant aspect of this bill. Prohibiting the drug testing of individuals in order to receive or deny federal benefits is long been needed. New initiatives to expand access to treatment provides a well-considered six item list. Overall, there is everything to like about this bill and very little to criticize with an intelligent balance of enforcement needed for public health and evidence based drug education and flexibility for adult drug use."

1. Drug Policy Alliance. Summary of the Drug Policy Reform Act (DPRA) of 2021. June 15, 2021. 

https://drugpolicy.org/sites/default/files/dpra_summary_2021.06.11_v2.pdf

2. Sutton M. On 50th anniversary of “war on drugs,” new poll shows majority of voters support ending criminal penalties for drug possession, think drug war is a failure. June 9, 2021. 

https://drugpolicy.org/press-release/2021/06/50th-anniversary-war-drugs-new-poll-shows-majority-voters-support-ending

3. Drug Policy Alliance. It’s time for the US to decriminalize drug use and possession. July 2017. 

https://drugpolicy.org/resource/its-time-us-decriminalize-drug-use-and-possession

The Drug Policy Reform Act, introduced today, intends to decriminalize drug use and possession, providing health-centered approaches and rehabilitation instead.

A Bill to End the War on Drugs

“Brain activity can be understood, that is, has meaning, only to the extent that it is a representation of the state of the body, of the external world, or of a potential behavior. Just as it would be pointless to analyze a book by investigating the chemical composition of paper and ink, a reductionist analysis of brain activity, that is, taking it apart and analyzing its nucleic acids, enzymes, receptors, and ion channels, fails to explain what brain activity accomplishes. The neuroscience of meaning requires experiments that study brain activity as the body moves through the world or as people describe their experience.”

- Howard Fields, Setting the Stage for Pain: Allegorical Tales From Neuroscience

The English word pain is derived from the Latin word poena, meaning penalty or punishment. Because of the intrinsically intimate and subjective nature of pain, philosophers and medical providers struggle to find a definitive definition of the word. It is variable through references, authors, and times, with conceptualizations focusing alternately on the biomedical, emotional, or behavioral components of the phenomenon. The philosopher René Descartes’ mechanistic conceptualization of pain as a sensation, where the animal merely reacts to the noxious stimulus, dominated scientific and folk beliefs about pain into the mid-20th century.

 The more modern emergence of the concept of being-in-pain, which includes the subjectivity of the individual in the experience, opens the door for a bigger involvement of mental health professionals in pain management.

 International Association for the Study of Pain

 coined a new definition of pain in 1979: “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

 This flexible definition acknowledges the sensory, cognitive, affective, and motivational processes that influence the experience of pain and allows for a broader exploration of its subjectivity. It trades a purely neurological view for a more holistic conceptualization that considers the totality of the pain and, more importantly, of the patient.

The differentiation between acute and chronic pain has proven to be clinically useful for tailoring interventions. Traditionally, the distinction between acute and chronic pain has relied upon a single continuum of time, with the designation of an arbitrary interval as a transition point, most commonly between 3 and 6 months. Another way to characterize chronic pain is pain that extends beyond the expected period of healing—assuming one knows what that should be.

Both acute and chronic pain are major public health problems with high health care costs and resource requirements. According to a 

, the conservative estimate of the health care cost of pain is around $560 to $635 billion annually, which is significantly greater than that of heart disease, cancer, or even diabetes mellitus.

 Because of this high prevalence and significant morbidity, pain has earned the designation of “the fifth vital sign.”

Despite these tremendous expenses and heroic efforts (using sophisticated technology, biomedical advances, and ever-growing research), most pain conditions have no final options for a cure. The only potent analgesics available are opioids, which can be problematic given the current opioid epidemic in Western countries. However, with the broader and multifaceted understanding of pain, patient care has moved from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient. To achieve this goal, the clinical integration of mental health providers in pain management teams has become more widespread.

The Relationship Between the Experience of Pain and Mental Health

If we agree with Ludwig Wittgenstein, PhD, who posited that “words are connected with the primitive, the natural expressions of the sensations and are used in their place,”

 it is not hard to see that even in the everyday language about pain, there exists a significant overlap between the purely physical experience of pain and the consequent subjective emotional aspects that arise with it. It might even seem that the connection transcends all elaborate philosophical theories and is deeply felt and expressed on an instinctual level. The most obvious example of the connection is that expressions like “broken-hearted” or “a slap in the face” are often used in multiple languages to describe experiences of physical as well as emotional, psychological, or even spiritual suffering.

This intimate and intricate relationship is also well understood even if one chooses to look at it from a purely neurobiological perspective. Although pain might initially originate from peripheral sensory receptors, the experience of pain is not complete without the 

modulatory involvement of the central nervous system

 Afferent stimuli from the thalamus, the limbic system, and cortical structures like the frontal lobe and the somatosensory cortex amplify or diminish the peripheral painful stimuli and add a subjective emotional component to the sensation. Functional imaging techniques and direct brain stimulation studies have demonstrated a striking overlap between central structures implicated in the 

 In addition, recent studies have described how chronic pain changes grey matter in the brain, resulting in secondary psychiatric symptoms and disorders. These studies thus emphasize a 

Figure 1. Common Brain Areas Implicated in Both Pain and Pleasure Processing

An individual’s experience of pain cannot be understood in a sterile context. With this conceptualization comes the possibility of applying psychological principles to the treatment of pain. Cognitive behavioral theories of pain are based on the premise that cognitions, emotions, behaviors, and physical sensations are all interrelated and exist within a particular context.

 Psychologists observe that changes in any of these areas can have wide-ranging influences through a circular effect on each other.

 illustrates how the different components of cognitive behavioral therapy (CBT) interact with each other to create vicious cycles, which in turn can cause a clinical increase in symptoms. From an interpersonal perspective, it is also clear that persistent personality traits can influence the subjective experience and expression of pain. Specific defensive and coping styles in an individual may create a particular and sometimes 

 Finally, although there is limited interest in the psychodynamic perspective of pain, multiple authors have argued that patients communicate on multiple conscious and unconscious levels through bodily manifestations, and that pain expressions hold 

 that warrant psychological and psychoanalytic exploration.

Figure 2. The Application of Cognitive-Behavioral Theory on the Experience of Pain

The Empirical Evidence for an Interdisciplinary Approach to Chronic Pain

From a more practical standpoint, evidence-based medicine shows a significant association between pain and mental health disorders and symptoms. There exists a statistically important comorbidity between acute and chronic pain and depressive disorders, anxiety disorders, substance use disorders, and personality disorders.

 Empirical evidence shows higher efficacy for the multidisciplinary and interdisciplinary management of pain that is based on the biopsychosocial model, which combines physical therapy, pain management by medication, patient education, ergonomic training, psychiatric treatment, and psychotherapy, among others. These interventions have shown significant results on the ratings of pain intensity scores, as well as on the quality-of-life measures that encompass both mental health and the functional impacts.

The Role of the Consultation-Liaison Psychiatrist in the Management of Pain

Consultation-liaison (C-L) psychiatrists are key members and leaders of interdisciplinary pain management teams. Psychiatry residents get the most 

 during the substance abuse/addictions (60%) and the C-L psychiatry (57%) rotations.

C-L psychiatrists are uniquely qualified to help patients with pain and play an important role in the pain management team. Although most primary care physicians and medical specialists can diagnose and initiate the treatment of psychiatric disorders, C-L subspecialists can diagnose more subtle and complex mood or anxiety disorders, substance use disorders, or personality disorders in a general medical setting. They can also participate in the pharmacological and even interventional management of pain, detect possible drug-drug interactions in these medically complex patients, and screen for possible medication side effects.

In addition, as the name of the specialty reveals, C-L psychiatrists are experts in bridging the gap between the patient and the other medical teams. They can relay messages in an empathic and understanding way and bring the goals of treatment into alignment with the patient’s values, preferences, and styles. Their integrated view of patients allows for reflection on behavioral, interpersonal, and psychodynamic formulations of the patient’s pain experience that can be communicated to the team to personalize the treatment and thus improve the quality of the care. 

 details the separate and overlapping roles of the pain specialist and the C-L psychiatrist.

Figure 3. The Separate and Overlapping Roles of the Pain Specialist and the Consultation Liaison Psychiatrist

Exploring the Future of C-L Psychiatry Within Pain Management Teams

 showed a national improvement of pain education in psychiatry training.

 The investigators found that more than two-thirds (70%) of program directors supported having psychiatry residents receive education and training in chronic pain management. This is a significant improvement from the less than 50% found in the 

The increase in pain management education is not limited to psychiatry residency; it also currently includes more continuing medical education (CME) focused on psychiatric aspects of pain, medication management of pain, meditation, CBT, and other strategies.

 This is particularly true for C-L psychiatrists, whose national professional organization, the 

Academy of Consultation-Liaison Psychiatry

, specifically includes CME for chronic pain as well as special interest groups for palliative medicine, addiction and toxicology, and collaborative and integrated care, among others.

Overall, the future of this integrated approach to pain with the inclusion of C-L psychiatrists looks bright. Encouraging systemic changes are starting to occur, including changes to reimbursement for medical services (meaning procedural and nonprocedural pain interventions will be more equally compensated). They also include changes to the referral processes between specialists, making the processes more efficient and allowing the emergence of bigger interdisciplinary teams.

We believe that an integrated treatment actively involves C-L psychiatry which, in the words of 

, constitutes the final missing P in the management of pain,

 and which can significantly improve health outcomes and the quality of life of this patient population.

is a consultation-liaison psychiatrist and palliative care fellow at MedStar Washington Hospital Center in Washington, DC.

is clinical and deputy scientific director of the National Institute of Mental Health and the National Institutes of Health, and acting clinical director of the National Center for Complementary and Integrative Health, all in Bethesda, MD.

Meditations on First Philosophy: With Selections From the Objections and Replies

. Moriarty M, trans. Oxford University Press; 2008.

The International Association for the Study of Pain definition of pain: as valid in 2018 as in 1979, but in need of regularly updated footnotes

3. Mehta A, Chan LS. Understanding of the concept of “total pain”: a prerequisite for pain control. 

The economic costs of pain in the United States

. Anscombe GEM, trans. Wiley-Blackwell, 1997.

Pain and suicidality: insights from reward and addiction neuroscience

A common neurobiology for pain and pleasure

Chronic pain may change the structure of the brain

New evidence for a pain personality? a critical review of the last 120 years of pain and personality

Parallel pains and dynamic dilemmas: psychodynamic considerations in approaching and managing chronic physical pain

Epidemiology of pain and relation to psychiatric disorders

Prog Neuropsychopharmacol Biol Psychiatry

13. Ilgen MA, Kleinberg F, Ignacio RV, et al. 

Noncancer pain conditions and risk of suicide

14. Scascighini L, Toma V, Dober-Spielmann S, Sprott H. 

Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes

15. Gerdle B, Åkerblom S, Brodda Jansen G, et al. 

Who benefits from multimodal rehabilitation - an exploration of pain, psychological distress, and life impacts in over 35,000 chronic pain patients identified in the Swedish Quality Registry for Pain Rehabilitation

The status of pain medicine education in psychiatry: a survey of residency training program directors

17. Majeed MH, Ali AA, Metzger S, Sudak DM. 

Pain management education and training during psychiatry residency: a report on national progress

18. Balon R, Morreale MK, Coverdale JH, et al. 

The role of psychiatric education in pain management

19. Academy of Consulation-Liaison Psychiatry. CLP 2020: delivering our vision of integrated care. 2020. Accessed March 22, 2021. 

The missing p in psychiatric training: why it is important to teach pain to psychiatrists

With a broader and multifaceted understanding of pain, patient care can move from a focus on eradicating pain, as based on objective pain scores, to improving the patient’s quality of life, while simultaneously decreasing pain to a level that is acceptable to the individual patient.

The Final “P” in Pain Management

In Belgium, the Netherlands, and Luxemburg over a hundred psychiatric patients a year receive medical aid in dying (MAID). They do not need to have a terminal condition, only a degree of suffering that they find intolerable. This could include mental suffering, brought on, for instance, by depression.

MAID laws are now passing in the United States, and psychiatrists may soon face a difficult question. Should they help patients, who say their psychiatric conditions are unbearable, end their lives? In this Mental Health Minute, Mark S. Komrad, MD, discusses the various forms of MAID and makes a case against them, especially for psychiatric patients.

Read Komrad’s full feature article on MAID 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland, clinical assistant professor of Psychiatry at the University of Maryland, and Teaching Faculty of Psychiatry at Tulane University in New Orleans.

Should psychiatrists ever assist in suicide? 

Medical aid in dying is available for psychiatric patients in European countries and Canada. Will the United States be next? 

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

 and the importance of its approval by the US Food and Drug Administration. 

is a practicing psychiatrist with a subspecialty in child and adolescent psychiatry, clinical researcher, and president of the Center for Psychiatry and Behavioral Medicine, Inc. in Las Vegas.

This new medication is a huge leap forward for treating attention-deficit/hyperactivity disorder. 

A Welcome Addition to the Child and Adolescent ADHD Armamentarium

is a clinical researcher in the Department of Psychiatry and Behavioral Sciences at the University of Minnesota Medical School and a doctoral student in counseling psychology at Saint Mary’s University of Minnesota.

is a master’s-level licensed psychologist. She is a doctoral candidate in the Department of Family Social Science at the College of Education and Human Development, University of Minnesota, and teaches in the psychology department at St. Catherine University.

VanMeter and Cichetti define resilience as “a dynamic developmental process that encompasses an individual’s capacity to adapt positively following significant adversity.”

 While some researchers have conceptualized resilience as 

 many clinicians and researchers view it as a multidimensional and transactional process unfolding across the lifespan. When considering resilience in individuals recovering from a first episode of psychosis (FEP), it is important to remember that this condition usually develops over an extended period of time and culminates in a psychotic disorder that may further languish for months or even years before proper treatment is procured. Even when effective treatment for FEP is obtained, it rarely eliminates all the symptoms and dysfunction. Individuals are still left struggling to cope with an often chronic and unpredictable illness and, while trying to make sense of their experiences, they must struggle to put their lives back together as best as they can. Therefore, understanding the nature of resilience in individuals with FEP is a uniquely complex undertaking.

Researchers have found that resilience in individuals with FEP is 

 While there is no single measure of resilience, certain findings can help clinicians better understand resilience in this population. First, resilience is associated with greater improvements in functioning for individuals with FEP as well as with multiple-episode psychosis.

 Furthermore, no strong evidence suggests that individuals with FEP are more or less resilient than those experiencing a more prolonged course of schizophrenia. Second, little evidence indicates that greater resilience is associated with less severe positive symptoms. Conversely, resilience does appear to be related to negative symptoms and mood difficulties, meaning that higher resilience is associated with lower negative symtpoms.

 This evidence suggests that targeting resilience could improve functioning. Similarly, it shows that improving mood and reducing negative symptoms could promote resilience. While pharmacological treatments target positive symptoms, treating negative symptoms requires interventions that address mood, negative emotions, and motivation.

Recovery from FEP can mean more than reduction of positive symptoms. It also offers an opportunity to cultivate resiliency. Early intervention programs such as NAVIGATE, which incorporate strengths-based and resilience-focused principles, are anchored by the view that recovery transcends the alleviation of symptoms and aims at the experience of positive emotions, satisfaction, and promotion of 

 A core intervention component of the NAVIGATE program is Individual Resiliency Training (IRT).

IRT is a module-based approach to treatment that specifically aspires to promote self-efficacy and self-determination, hope for the future, meaning in life, and personal well-being in the context of teaching information and 

 Modules within IRT—and the NAVIGATE model more broadly—foster resiliency in individuals with FEP by providing guidance and training in numerous areas: enhancing positive emotions; cultivating an internal locus of control through shared decision-making; increasing cognitive flexibility and adaptive coping skills; increasing a sense of meaning and purpose through motivational enhancement and collaboration with natural supports (eg, relationships within family, school, work, and community environments); and fostering growth through cultivating a framework for understanding and processing the psychotic episode.

Throughout IRT, modules help patients develop their own personal resiliency story. This narrative of cultivating resilience is woven across the standard and individualized modules and creates opportunities for individuals to identify their own resilient qualities, highlight past personal stories of resiliency, build resilience through enhancing personal strengths, and identify the good things that happen every day.

 Similarly, these modules foster growth and resiliency by helping the patient to process their psychotic experiences and learn positive coping strategies.

The concept of resiliency in IRT is based on the broaden-and-build theory, which posits that the experience of positive emotions broadens an individual’s awareness, increases their cognitive flexibility, facilitates adaptive coping strategies, counteracts negative emotions, and encourages novel and exploratory thoughts and actions. Together, this leads to increased resources and opportunities to 

 Based on positive psychology interventions, the skills and strategies learned in IRT emphasize a behavioral approach, which increases the experience of positive emotions and focuses on building gratitude, prolonging pleasure through savoring, enhancing positive relationships, increasing kindness, and improving well-being.

Integrating Resiliency Into Clinical Practice

The implications of incorporating resiliency strategies into treatment could be wide-reaching. Environments that foster self-determination may promote motivation, well-being, and overall growth in 

 We will discuss 3 opportunities to build resiliency and self-determination within clinical encounters: shared decision making, establishing and following up on goals, and incorporating strengths into treatment.

Shared decision making is critical to empowering individuals with mental illness to become knowledgeable and participate in managing their illness.

 In the NAVIGATE model, prescribers use shared decision-making to select medications based on 

 This approach promotes autonomy and supports resiliency by facilitating choice, hope, and collaboration.

 The shared decision-making process begins by including the individual in the treatment discussions. During the process, practitioners should encourage opportunities for individuals to express their concerns about treatment, learn and discuss treatment options, ensure that patients are happy with the treatment decision, and provide time to review the treatment decision.

By identifying goals and taking the necessary steps toward achieving these goals, positive behaviors are fostered and meaningful outcomes become possible. In fact, the achievement of personal goals is associated with increases in 

 Practitioners provide opportunities for patients to reengage in their lives and promote recovery by developing goals that are personally relevant and challenging, and that focus on proximal outcomes. Patients have greater opportunities for recovery when practitioners provide ongoing feedback on goals that is structured and timely.

 In addition, clinicians who ask about and support goal progress promote self-efficacy in their patients and increase their expectations for success.

 In early-intervention treatment, clinicians can ask patients to share their goals, ask about progress toward a goal, or problem-solve a challenge or obstacle. Role-playing can help patients practice for success and increase their motivation to pursue a goal.

One of the best ways to foster resiliency is by building on existing strengths. Character strengths are defined as positive trait-like capacities associated with thinking, feeling, and behaving in ways that benefit an individual and others

 These strengths are associated with fulfillment and the pursuit of happiness, and they are a key feature of 

 The Brief Strengths Test can be used to assess character strengths, and it has successfully been implemented in IRT sessions with individuals with FEP.

 Ascertaining patients’ strengths can help make their relapse prevention plan more potent, by assisting them in identifying coping skills as well as crafting response strategies for early warning signs or triggers. These strengths can also foster engagement in healthy lifestyle strategies.

For example, if among a patient’s strengths is their ability to see beauty in nature, a helpful coping strategy could be taking a walk outside and paying close attention to the living things in the natural world. Since many coping strategies associated with character strengths have been compiled, clinicians can readily share these with their 

Additionally, character strengths can present opportunities to address difficulties and challenges, such as medication adherence.

 For example, if a patient’s strength is hope, the clinician can discuss how to cultivate a positive attitude about long-term mental health and explain how taking medication will contribute to their overall well-being in the future.

“Leroy” is a man with schizophrenia, aged 24 years. He struggles with delusional beliefs that the government is watching him and spying on him. He also hears voices that tell him he is a bad person and will never succeed in life. He currently lives at home with his parents and is a part-time college student. He is engaged in treatment with a coordinated specialty care program for individuals with FEP that includes therapy, supported employment and education, and antipsychotic medications. Leroy’s parents also participate in family education.

Leroy is currently participating in IRT with a therapist, who has begun IRT’s Assessment and Goal Setting Module. When Leroy completed the Brief Strengths Test, he identified his top 5 strengths as creativity, spirituality, love of learning, appreciation of beauty, and gratitude. Afterward, Leroy became increasingly paranoid about cars driving past his house; he began spending more time alone in his room, and he reported that the voices became louder.

In IRT, the therapist worked with Leroy to develop some coping skills to decrease his distress and support his goal of completing college. The therapist noted that listening to music and talking to a supportive friend are helpful coping strategies, and suggested that Leroy use one or more of his identified strengths to pinpoint other possible strategies. Leroy had discussed his interest in creative writing and exploring different religious beliefs. Thus, in collaboration with the therapist, Leroy developed a plan to try writing every day to engage his creativity. Leroy also said that he was interested in writing poetry and short stories about his spiritual beliefs and practices, which would engage his strength of spirituality.

When the therapist followed up in the next session, Leroy shared poetry he had written and was obviously engaged in the session when he did so. Although Leroy continued to struggle with paranoia, he noticed that the voices were quieter when he was writing. At the end of the session, Leroy decided to add writing as a daily coping skill that he could use to help him spend more time on his interests and less on his worries about the government. As Leroy’s symptoms improved, he decided to add a short-term goal about creating a collection of his short stories and poems to highlight his experiences with mental health symptoms.

Family members and supportive friends are another important resource for fostering resiliency. The connections that patients have to others promote strength and support 

 Individuals with FEP often live with their family members, who are in an ideal position to support their loved one’s resiliency. It is therefore important to teach family members positive psychology strategies. For example, the “good things” activity is an evening reflective exercise in which the patient lists up to 3 good things that happened during the day. For each good thing, the patient should identify the positive emotion associated with it and aim to determine why the good thing happened.

 When this activity is done daily, patients have an opportunity to establish a routine that they can share with family members and choose to continue voluntarily.

Simple but powerful strategies for drawing on patients’ existing character strengths and long-term goals. 

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